1
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Hughes AD, Teachey DT, Diorio C. Riding the storm: managing cytokine-related toxicities in CAR-T cell therapy. Semin Immunopathol 2024; 46:5. [PMID: 39012374 PMCID: PMC11252192 DOI: 10.1007/s00281-024-01013-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/18/2024] [Indexed: 07/17/2024]
Abstract
The advent of chimeric antigen receptor T cells (CAR-T) has been a paradigm shift in cancer immunotherapeutics, with remarkable outcomes reported for a growing catalog of malignancies. While CAR-T are highly effective in multiple diseases, salvaging patients who were considered incurable, they have unique toxicities which can be life-threatening. Understanding the biology and risk factors for these toxicities has led to targeted treatment approaches which can mitigate them successfully. The three toxicities of particular interest are cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and immune effector cell-associated hemophagocytic lymphohistiocytosis (HLH)-like syndrome (IEC-HS). Each of these is characterized by cytokine storm and hyperinflammation; however, they differ mechanistically with regard to the cytokines and immune cells that drive the pathophysiology. We summarize the current state of the field of CAR-T-associated toxicities, focusing on underlying biology and how this informs toxicity management and prevention. We also highlight several emerging agents showing promise in preclinical models and the clinic. Many of these established and emerging agents do not appear to impact the anti-tumor function of CAR-T, opening the door to additional and wider CAR-T applications.
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Affiliation(s)
- Andrew D Hughes
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caroline Diorio
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Immune Dysregulation Frontier Program, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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2
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Ghilardi G, Paruzzo L, Svoboda J, Chong EA, Shestov AA, Chen L, Cohen IJ, Gabrielli G, Nasta SD, Porazzi P, Landsburg DJ, Gerson JN, Carter J, Barta SK, Yelton R, Pajarillo R, Patel V, White G, Ballard HJ, Weber E, Napier E, Chong ER, Fraietta JA, Garfall AL, Porter DL, Milone MC, O’Connor R, Schuster SJ, Ruella M. Bendamustine lymphodepletion before axicabtagene ciloleucel is safe and associates with reduced inflammatory cytokines. Blood Adv 2024; 8:653-666. [PMID: 38113468 PMCID: PMC10839610 DOI: 10.1182/bloodadvances.2023011492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/27/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023] Open
Abstract
ABSTRACT Lymphodepletion (LD) is an integral component of chimeric antigen receptor T-cell (CART) immunotherapies. In this study, we compared the safety and efficacy of bendamustine (Benda) to standard fludarabine/cyclophosphamide (Flu/Cy) LD before CD19-directed, CD28-costimulated CART axicabtagene ciloleucel (axi-cel) for patients with large B-cell lymphoma (LBCL) and follicular lymphoma (FL). We analyzed 59 patients diagnosed with LBCL (n = 48) and FL (n = 11) consecutively treated with axi-cel at the University of Pennsylvania. We also analyzed serum samples for cytokine levels and metabolomic changes before and after LD. Flu/Cy and Benda demonstrated similar efficacy, with complete remission rates of 51.4% and 50.0% (P = .981), respectively, and similar progression-free and overall survivals. Any-grade cytokine-release syndrome occurred in 91.9% of patients receiving Flu/Cy vs 72.7% of patients receiving Benda (P = .048); any-grade neurotoxicity after Flu/Cy occurred in 45.9% of patients and after Benda in 18.2% of patients (P = .031). In addition, Flu/Cy was associated with a higher incidence of grade ≥3 neutropenia (100% vs 54.5%; P < .001), infections (78.4% vs 27.3%; P < .001), and neutropenic fever (78.4% vs 13.6%; P < .001). These results were confirmed both in patients with LBCL and those with FL. Mechanistically, patients with Flu/Cy had a greater increase in inflammatory cytokines associated with neurotoxicity and reduced levels of metabolites critical for redox balance and biosynthesis. This study suggests that Benda LD may be a safe alternative to Flu/Cy for CD28-based CART CD19-directed immunotherapy with similar efficacy and reduced toxicities. Benda is associated with reduced levels of inflammatory cytokines and increased anabolic metabolites.
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Affiliation(s)
- Guido Ghilardi
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Luca Paruzzo
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Oncology, University of Turin, Turin, Italy
| | - Jakub Svoboda
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Eise A. Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alexander A. Shestov
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Linhui Chen
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ivan J. Cohen
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Giulia Gabrielli
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin, Italy
| | - Sunita D. Nasta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Patrizia Porazzi
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Daniel J. Landsburg
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - James N. Gerson
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jordan Carter
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Stefan K. Barta
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rebecca Yelton
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Raymone Pajarillo
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Vrutti Patel
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Griffin White
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Hatcher J. Ballard
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Weber
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ellen Napier
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emeline R. Chong
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph A. Fraietta
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
| | - Alfred L. Garfall
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David L. Porter
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael C. Milone
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Roderick O’Connor
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephen J. Schuster
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marco Ruella
- Lymphoma Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, PA
- Division of Hematology-Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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3
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Ren X, Zhang G, Li G, Wang Y. Chimeric antigen receptor T-cell therapy-induced nervous system toxicity: a real-world study based on the FDA Adverse Event Reporting System database. BMC Cancer 2024; 24:10. [PMID: 38166723 PMCID: PMC10762809 DOI: 10.1186/s12885-023-11753-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/12/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Nervous system toxicity (NST) is one of the most frequent and dangerous side effects of chimeric antigen receptor T-cell (CAR-T) therapy, which is an effective treatment for related tumors in most relapsed/refractory (r/r) hematologic malignancies. Current clinical trial data do not fully reflect the real-world situation. Therefore, this study evaluated the NST of CAR-T therapy using the FDA Adverse Event Reporting System (FAERS). METHODS Data were retrieved from FAERS for the period from January 1, 2017 to March 31, 2023. Disproportionality analysis and Bayesian analysis were used for data mining. The reporting odds ratio (ROR) for NST with 95% confidence interval (CI) was calculated for each CAR-T product. The time to onset (TTO) and clinical outcomes due to CAR-T therapy-associated NST were assessed. RESULTS Overall, 6946 cases of NST associated with CAR-T therapy were identified. The patients had a median age of 61 years (interquartile range [IQR]: 47-69 years). Significant signals were observed for all CAR-T products (ROR: 2.19, 95% CI: 2.13-2.44). Anti-CD19 CAR-T products showed a higher NST signal than anti-B cell maturation antigen (BCMA) CAR-T products (ROR025 2.13 vs. 1.98). Brexucabtagene autoleucel (ROR: 3.17, 95% CI: 2.90-3.47) and axicabtagene ciloleucel (ROR: 2.92, 95% CI: 2.81-3.03) had the two highest NST signals. For the preferred term "brain edema," the highest signals were obtained for CD28 CAR-T products. The median TTO of NST for all CAR-T products was 7 days (IQR: 3-17 days). The proportion of death, life-threatening and hospitalization adverse events associated with NST was 20.06%, 7.21%, and 32.70%, respectively. The proportion of death outcomes was higher in patients treated with tisagenlecleucel (30.36%) than in those treated with other CAR-T products, except ciltacabtagene autoleucel (P < 0.001). The proportion of hospitalizations was significantly higher for lisocabtagene maraleucel-associated NST (53.85%) than for other drugs, except for ciltacabtagene autoleucel (P < 0.001). CONCLUSIONS NST is more closely associated with anti-CD19 CAR-Ts and CAR-Ts containing CD28. Serious NST (brain oedema) is likely to occur with CAR-Ts that contain CD28. CAR-T-related NST warrants greater attention owing to the high proportion of serious adverse events and delayed NST.
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Affiliation(s)
- Xiayang Ren
- Department of Pharmacy, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Guanmin Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Pharmacy, Peking University Cancer Hospital & Institute, Beijing, China
| | - Guohui Li
- Department of Pharmacy, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - Yanfeng Wang
- Department of Comprehensive Oncology, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17, Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
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4
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McNerney KO, Hsieh EM, Shalabi H, Epperly R, Wolters PL, Hill JA, Gardner R, Talleur AC, Shah NN, Rossoff J. INSPIRED Symposium Part 3: Prevention and Management of Pediatric Chimeric Antigen Receptor T Cell-Associated Emergent Toxicities. Transplant Cell Ther 2024; 30:38-55. [PMID: 37821079 PMCID: PMC10842156 DOI: 10.1016/j.jtct.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
Chimeric antigen receptor (CAR) T cell (CAR-T) therapy has emerged as a revolutionary cancer treatment modality, particularly in children and young adults with B cell malignancies. Through clinical trials and real-world experience, much has been learned about the unique toxicity profile of CAR-T therapy. The past decade brought advances in identifying risk factors for severe inflammatory toxicities, investigating preventive measures to mitigate these toxicities, and exploring novel strategies to manage refractory and newly described toxicities, infectious risks, and delayed effects, such as cytopenias. Although much progress has been made, areas needing further improvements remain. Limited guidance exists regarding initial administration of tocilizumab with or without steroids and the management of inflammatory toxicities refractory to these treatments. There has not been widespread adoption of preventive strategies to mitigate inflammation in patients at high risk of severe toxicities, particularly children. Additionally, the majority of research related to CAR-T toxicity prevention and management has focused on adult populations, with only a few pediatric-specific studies published to date. Given that children and young adults undergoing CAR-T therapy represent a unique population with different underlying disease processes, physiology, and tolerance of toxicities than adults, it is important that studies be conducted to evaluate acute, delayed, and long-term toxicities following CAR-T therapy in this younger age group. In this pediatric-focused review, we summarize key findings on CAR-T therapy-related toxicities over the past decade, highlight emergent CAR-T toxicities, and identify areas of greatest need for ongoing research.
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Affiliation(s)
- Kevin O McNerney
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Emily M Hsieh
- Pediatric Hematology/Oncology, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine of USC, Los Angeles, California
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Rebecca Epperly
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Joshua A Hill
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rebecca Gardner
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Aimee C Talleur
- Department of Bone Marrow Transplant, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Jenna Rossoff
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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5
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Zhou LL, Ye SG, Li P, Tang XC, Liang AB. [Effect of early tocilizumab intervention on patients with cytokine release syndrome following chimeric antigen receptor T cell therapy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2023; 44:1022-1026. [PMID: 38503526 PMCID: PMC10834881 DOI: 10.3760/cma.j.issn.0253-2727.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Indexed: 03/21/2024]
Abstract
Objective: This study aimed to evaluate the effect of early tocilizumab intervention to relieve cytokine release syndrome (CRS) following chimeric antigen receptor T cell (CAR-T) therapy. Methods: Twenty-two patients with acute lymphoblastic leukemia who received tocilizumab to relieve CRS response after CAR-T cell infusion in our research center from October 2015 to July 2021 were retrospectively analyzed. According to the timing of tocilizumab intervention, patients were divided into the conventional and early intervention groups. Patients who received tocilizumab treatment after sustained high fever for 4 h were included in the early intervention group. The clinical data, CRS grade, and event-free survival (EFS) between the two groups were evaluated. Results: Compared with patients who used tocilizumab after severe CRS, no patients in the early intervention group died from CRS, and there was no increased risk of neurotoxicity. Eleven patients (84.62%) achieved complete remission with minimal residual lesions. The median EFS of patients in the early intervention and conventional groups was 2 (95% CI 0-5) and 7 (95% CI 3-11) months, respectively. Conclusion: Early tocilizumab intervention in patients with CRS reduces severe CRS and provides a more optimized therapeutic strategy for CRS caused by CAR-T cell therapy.
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Affiliation(s)
- L L Zhou
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - S G Ye
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - P Li
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - X C Tang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - A B Liang
- Department of Hematology, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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6
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Epperly R, Shah NN. Long-term follow-up of CD19-CAR T-cell therapy in children and young adults with B-ALL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:77-83. [PMID: 38066902 PMCID: PMC10727115 DOI: 10.1182/hematology.2023000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The tremendous successes of CD19-directed CAR T cells in children and young adults with B-cell acute lymphoblastic leukemia (B-ALL) has led to the more widespread use of this important treatment modality. With an ability to induce remission and potentially lead to long-term survival in patients with multiply relapsed/chemotherapy refractory disease, more children are now receiving this therapy with the hope of inducing a long-term durable remission (with or without consolidative hematopoietic cell transplantation). While overcoming the acute toxicities was critical to its broad implementation, the emerging utilization requires close evaluation of subacute and delayed toxicities alongside a consideration of late effects and issues related to survivorship following CAR T cells. In this underexplored area of toxicity monitoring, this article reviews the current state of the art in relationship to delayed toxicities while highlighting areas of future research in the study of late effects in children and young adults receiving CAR T cells.
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Affiliation(s)
- Rebecca Epperly
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD
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7
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Hansen DK, Liu YH, Ranjan S, Bhandari H, Potluri R, McFarland L, De Braganca KC, Huo S. The Impact of Outpatient versus Inpatient Administration of CAR-T Therapies on Clinical, Economic, and Humanistic Outcomes in Patients with Hematological Cancer: A Systematic Literature Review. Cancers (Basel) 2023; 15:5746. [PMID: 38136292 PMCID: PMC10741664 DOI: 10.3390/cancers15245746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/01/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
Although chimeric antigen receptor (CAR)-T cell therapies are typically administered in the inpatient setting, outpatient administration is rapidly expanding. However, there is limited summarized evidence comparing outcomes between outpatient and inpatient administration. This systematic literature review aims to compare the safety, efficacy, quality of life (QoL), costs, and healthcare resource utilization (HCRU) outcomes in patients with hematological cancer who are administered CAR-T therapy in an outpatient versus an inpatient setting. Publications (2016 or later) that reported the outcomes of interest in patients treated with a CAR-T therapy in both outpatient and inpatient settings, or only the outpatient setting, were reviewed. In total, 38 publications based on 21 studies were included. Safety findings suggested the comparable frequency of adverse events in the two settings. Eleven studies that reported data in both settings showed comparable response rates (80-82% in outpatient and 72-80% in inpatient). Improvements in the QoL were observed in both settings while costs associated with CAR-T therapy were lower in the outpatient setting. Although unplanned hospitalizations were higher in the outpatient cohort, overall HCRU was lower. Outpatient administration of CAR-T therapy appears to have comparable outcomes in safety, efficacy, and QoL to inpatient administration while reducing the economic burden.
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Affiliation(s)
- Doris K. Hansen
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Yi-Hsuan Liu
- Janssen Scientific Affairs, Horsham, PA 19044, USA
| | | | | | | | | | | | - Stephen Huo
- Janssen Scientific Affairs, Horsham, PA 19044, USA
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8
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Talbot LJ, Lautz TB, Aldrink JH, Ehrlich PF, Dasgupta R, Mattei P, Tracy ET, Glick RD, Grant CM, Brown EG, Christison-Lagay ER, Rodeberg DA. Implications of Immunotherapy for Pediatric Malignancies: A Summary from the APSA Cancer Committee. J Pediatr Surg 2023; 58:2119-2127. [PMID: 37550134 DOI: 10.1016/j.jpedsurg.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/01/2023] [Accepted: 07/01/2023] [Indexed: 08/09/2023]
Abstract
Although survival for many pediatric cancers has improved with advances in conventional chemotherapeutic regimens and surgical techniques in the last several decades, it remains a leading cause of disease-related death in children. Outcomes in patients with recurrent, refractory, or metastatic disease are especially poor. Recently, the advent of alternative classes of therapies, including immunotherapies, have revolutionized systemic treatment for pediatric malignancies. Several classes of immunotherapies, including chimeric antigen receptor (CAR) T cell therapy, transgenic T-cell receptor (TCR)-T cell therapy, bispecific T-cell engagers, and monoclonal antibody checkpoint inhibitors have been FDA-approved or entered early-phase clinical trials in children and young adults. The pediatric surgeon is likely to encounter these therapies during the care of children with malignancies and should be familiar with the classes of therapy, indications, adverse events, and potential need for surgical intervention in these cases. This review from the APSA Cancer Committee offers a brief discussion of the three most encountered classes of immunotherapy in children and young adults and discusses surgical relevance. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
| | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa, USA
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Christa M Grant
- Division of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Erin G Brown
- Division of Pediatric General and Thoracic Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Emily R Christison-Lagay
- Division of Pediatric Surgery, Department of Surgery, Yale School of Medicine, Yale-New Haven Children's Hospital, New Haven, CT, USA
| | - David A Rodeberg
- Division of Pediatric Surgery, Department of Surgery, East Carolina University, Greenville, NC, USA
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9
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Pinto SN, Liu CSJ, Nelson MD, Bluml S, Livingston D, Tamrazi B. Neuroimaging of complications arising after CD19 chimeric antigen receptor T-cell therapy: A review. J Neuroimaging 2023; 33:703-715. [PMID: 37327044 DOI: 10.1111/jon.13138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023] Open
Abstract
Chimeric antigen receptor (CAR) T cells targeting the CD19 (cluster of differentiation 19) cell surface glycoprotein have emerged as a highly effective immunologic therapy in patients with relapsed or refractory B-cell malignancies. The engagement of CAR T cells with CD19 on the surface of neoplastic B cells causes a systemic cytokine release, which can compromise the blood-brain barrier and cause an immune effector cell-associated neurotoxicity syndrome (ICANS). In a small proportion of ICANS patients who demonstrate neuroimaging abnormalities, certain distinct patterns have been recognized, including signal changes in the thalami, external capsule, and brainstem, the subcortical and/or periventricular white matter, the splenium of the corpus callosum, and the cerebellum. On careful review of the underlying pathophysiology of ICANS, we noticed that these changes closely mirror the underlying blood-brain barrier disruption and neuroinflammatory and excitotoxic effects of the offending cytokines released during ICANS. Furthermore, other uncommon complications of CD19 CAR T-cell therapy such as posterior reversible encephalopathy syndrome, ocular complications, and opportunistic fungal infections can be catastrophic if not diagnosed in a timely manner, with neuroimaging playing a significant role in management. In this narrative review, we will summarize the current literature on the spectrum of neuroimaging findings in ICANS, list appropriate differential diagnoses, and explore the imaging features of other uncommon central nervous system complications of CD19 CAR T-cell therapy using illustrative cases from two tertiary care institutions.
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Affiliation(s)
- Soniya N Pinto
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chia-Shang J Liu
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Marvin D Nelson
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Stefan Bluml
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - David Livingston
- Resident, Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Benita Tamrazi
- Division of Neuroradiology, Department of Radiology, Children's Hospital of Los Angeles, Los Angeles, California, USA
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10
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Morbelli S, Gambella M, Raiola AM, Ghiggi C, Bauckneht M, Raimondo TD, Lapucci C, Sambuceti G, Inglese M, Angelucci E. Brain FDG-PET findings in chimeric antigen receptor T-cell therapy neurotoxicity for diffuse large B-cell lymphoma. J Neuroimaging 2023; 33:825-836. [PMID: 37291470 DOI: 10.1111/jon.13135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/29/2023] [Accepted: 06/01/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Chimeric antigen receptor (CAR) T-cell therapy is potentially associated with treatment-related toxicities mainly consisting of cytokine release syndrome (CRS) and immune-effector cell-associated neurotoxicity syndrome (ICANS). We evaluated brain metabolic correlates of CRS with and without ICANS in diffuse large B-cell lymphoma patients treated with CAR-T. METHODS Twenty-one refractory DLCBLs underwent whole-body and brain [18 F]-fluorodeoxyglucose (FDG) PET before and 30 days after treatment with CAR-T. Five patients did not develop inflammatory-related side effects, 11 patients developed CRS, while in 5 patients CRS evolved in ICANS. Baseline and post-CAR-T brain FDG-PET were compared with a local controls dataset to identify hypometabolic patterns both at single-patient and group levels (p < .05 after correction for family-wise error [FWE). Metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were computed on baseline FDG-PET and compared between patients' subgroups (t-test). RESULTS ICANS showed an extended and bilateral hypometabolic pattern mainly involving the orbitofrontal cortex, frontal dorsolateral cortex, and anterior cingulate (p < .003 FWE-corrected). CRS without ICANS showed significant hypometabolism in less extended clusters mainly involving bilateral medial and lateral temporal lobes, posterior parietal lobes, anterior cingulate, and cerebellum (p < .002 FWE-corrected). When compared, ICANS showed a more prominent hypometabolism in the orbitofrontal and frontal dorsolateral cortex in both hemispheres than CRS (p < .002 FWE-corrected). Mean baseline MTV and TLG were significantly higher in ICANS than CRS (p < .02). CONCLUSIONS Patients with ICANS are characterized by a frontolateral hypometabolic signature coherently with the hypothesis of ICANS as a predominant frontal syndrome and with the more prominent susceptibility of frontal lobes to cytokine-induced inflammation.
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Affiliation(s)
- Silvia Morbelli
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Nuclear Medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy
| | - Massimiliano Gambella
- Department of Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Anna Maria Raiola
- Department of Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Chiara Ghiggi
- Department of Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Matteo Bauckneht
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Nuclear Medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy
| | - Tania Di Raimondo
- Nuclear Medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy
| | - Caterina Lapucci
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Genova, Italy
| | - Gianmario Sambuceti
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Nuclear Medicine Unit, Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy
| | - Matilde Inglese
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), IRCCS Ospedale Policlinico San Martino, University of Genoa, Genova, Italy
| | - Emanuele Angelucci
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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11
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Mao J, Chao K, Jiang FL, Ye XP, Yang T, Li P, Zhu X, Hu PJ, Zhou BJ, Huang M, Gao X, Wang XD. Comparison and development of machine learning for thalidomide-induced peripheral neuropathy prediction of refractory Crohn’s disease in Chinese population. World J Gastroenterol 2023; 29:3855-3870. [PMID: 37426324 PMCID: PMC10324537 DOI: 10.3748/wjg.v29.i24.3855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/07/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Thalidomide is an effective treatment for refractory Crohn’s disease (CD). However, thalidomide-induced peripheral neuropathy (TiPN), which has a large individual variation, is a major cause of treatment failure. TiPN is rarely predictable and recognized, especially in CD. It is necessary to develop a risk model to predict TiPN occurrence.
AIM To develop and compare a predictive model of TiPN using machine learning based on comprehensive clinical and genetic variables.
METHODS A retrospective cohort of 164 CD patients from January 2016 to June 2022 was used to establish the model. The National Cancer Institute Common Toxicity Criteria Sensory Scale (version 4.0) was used to assess TiPN. With 18 clinical features and 150 genetic variables, five predictive models were established and evaluated by the confusion matrix receiver operating characteristic curve (AUROC), area under the precision-recall curve (AUPRC), specificity, sensitivity (recall rate), precision, accuracy, and F1 score.
RESULTS The top-ranking five risk variables associated with TiPN were interleukin-12 rs1353248 [P = 0.0004, odds ratio (OR): 8.983, 95% confidence interval (CI): 2.497-30.90], dose (mg/d, P = 0.002), brain-derived neurotrophic factor (BDNF) rs2030324 (P = 0.001, OR: 3.164, 95%CI: 1.561-6.434), BDNF rs6265 (P = 0.001, OR: 3.150, 95%CI: 1.546-6.073) and BDNF rs11030104 (P = 0.001, OR: 3.091, 95%CI: 1.525-5.960). In the training set, gradient boosting decision tree (GBDT), extremely random trees (ET), random forest, logistic regression and extreme gradient boosting (XGBoost) obtained AUROC values > 0.90 and AUPRC > 0.87. Among these models, XGBoost and GBDT obtained the first two highest AUROC (0.90 and 1), AUPRC (0.98 and 1), accuracy (0.96 and 0.98), precision (0.90 and 0.95), F1 score (0.95 and 0.98), specificity (0.94 and 0.97), and sensitivity (1). In the validation set, XGBoost algorithm exhibited the best predictive performance with the highest specificity (0.857), accuracy (0.818), AUPRC (0.86) and AUROC (0.89). ET and GBDT obtained the highest sensitivity (1) and F1 score (0.8). Overall, compared with other state-of-the-art classifiers such as ET, GBDT and RF, XGBoost algorithm not only showed a more stable performance, but also yielded higher ROC-AUC and PRC-AUC scores, demonstrating its high accuracy in prediction of TiPN occurrence.
CONCLUSION The powerful XGBoost algorithm accurately predicts TiPN using 18 clinical features and 14 genetic variables. With the ability to identify high-risk patients using single nucleotide polymorphisms, it offers a feasible option for improving thalidomide efficacy in CD patients.
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Affiliation(s)
- Jing Mao
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Kang Chao
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Fu-Lin Jiang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Xiao-Ping Ye
- Department of Pharmacy, Guangdong Women and Children Hospital, Guangzhou 510000, Guangdong Province, China
| | - Ting Yang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Pan Li
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Xia Zhu
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Pin-Jin Hu
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Bai-Jun Zhou
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Min Huang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Xiang Gao
- Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
| | - Xue-Ding Wang
- Institute of Clinical Pharmacology, School of Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
- Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, Sun Yat-sen University, Guangzhou 510006, Guangdong Province, China
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12
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Yang X, Zhang B. A review on CRISPR/Cas: a versatile tool for cancer screening, diagnosis, and clinic treatment. Funct Integr Genomics 2023; 23:182. [PMID: 37231285 DOI: 10.1007/s10142-023-01117-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023]
Abstract
Cancer is one of the leading causes of death worldwide and it has the trend of increase incidence. However, in the past decades, as quickly developed new technologies and modified old techniques for cancer screening, diagnosis, and treatment, the cancer-caused mortality rates dropped quickly, and the survival times of cancer patients are enhanced. However, the current death rate is still about 50% and the survival patients always suffer from the side effect of current cancer treatments. Recently developed Nobel Prize-winning CRISPR/Cas technology provides new hope on cancer screening, early diagnosis, and clinic treatment as well as new drug development. Currently, four major CRISPR/Cas9-derived genome editors, CRISPR/Cas9 nucleotide sequence editor, CRISPR/Cas base editor (BE), CRISPR prime editor (PE), and CRISPR interference (CRISPRi) (including both CRISPRa and CRISPRr), were well developed and used to various research and applications, including cancer biology study and cancer screening, diagnosis, and treatment. Additionally, CRISPR/Cas12 and CRISPR/Cas13 genome editors were also widely used in cancer-related basic and applied research as well as treatment. Cancer-associated SNPs and genetic mutations as well as both oncogenes and tumor suppressor genes are perfect targets for CRISPR/Cas-based gene therapy for cancer treatment. CRISPR/Cas is also employed to modify and generate new Chimeric antigen receptor (CAR) T-cells for improving its safety, efficiency, and longer-time last for treating various cancers. Currently, there are many clinic trails of CRISPR-based gene therapy for cancer treatments. Although all CRISPR/Cas-derived genome and epigenome tools are promising methods for cancer biology study and treatment, the efficiency and long term-safety are still the major concerns for CRISPR-based gene therapy. Developing new CRISPR/Cas delivery methods and reducing the potential side effects, including off-target impacts, will enhance CRISPR/Cas application in cancer-related research, diagnosis, and therapeutical treatment.
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Affiliation(s)
- Xianguang Yang
- College of Life Science, Henan Normal University, Xinxiang, 453007, Henan, China.
| | - Baohong Zhang
- Department of Biology, East Carolina University, Greenville, NC, 27858, USA.
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13
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Santomasso BD, Gust J, Perna F. How I treat unique and difficult-to-manage cases of CAR T-cell therapy-associated neurotoxicity. Blood 2023; 141:2443-2451. [PMID: 36877916 PMCID: PMC10329188 DOI: 10.1182/blood.2022017604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023] Open
Abstract
With growing indications for chimeric antigen receptor (CAR) T-cell therapy, toxicity profiles are evolving. There is an urgent and unmet need of approaches to optimally manage emerging adverse events that extend beyond the standard paradigm of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome (ICANS). Although management guidelines exist for ICANS, there is little guidance on how to approach patients with neurologic comorbidities, and how to manage rare neurotoxicity presentations, such as CAR T-cell therapy-related cerebral edema, severe motor complications or late-onset neurotoxicity. In this study, we present 3 scenarios of patients treated with CAR T cells who develop unique types of neurotoxicity, and we describe an approach for the evaluation and management based on experience because objective data are limited. The goal of this study is to develop an awareness of emerging and unusual complications, discuss treatment approaches, and help institutions and health care providers establish frameworks to navigate how to best address unusual neurotoxicities to ultimately improve patient outcomes.
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Affiliation(s)
- Bianca D. Santomasso
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
- Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Juliane Gust
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA
- Seattle Children's Research Institute Center for Integrative Brain Research, Seattle, WA
| | - Fabiana Perna
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
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14
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Mucha SR, Rajendram P. Management and Prevention of Cellular-Therapy-Related Toxicity: Early and Late Complications. Curr Oncol 2023; 30:5003-5023. [PMID: 37232836 DOI: 10.3390/curroncol30050378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/28/2023] [Accepted: 05/02/2023] [Indexed: 05/27/2023] Open
Abstract
Chimeric Antigen Receptor T (CAR-T) cell therapy has dramatically changed prognosis and treatment of relapsed and refractory hematologic malignancies. Currently the 6 FDA approved products target various surface antigens. While CAR-T therapy achieves good response, life-threatening toxicities have been reported. Mechanistically, can be divided into two categories: (1) toxicities related to T-cell activation and release of high levels of cytokines: or (2) toxicities resulting from interaction between CAR and CAR targeted antigen expressed on non-malignant cells (i.e., on-target, off-tumor effects). Variations in conditioning therapies, co-stimulatory domains, CAR T-cell dose and anti-cytokine administration, pose a challenge in distinguishing cytokine mediated related toxicities from on-target, off-tumor toxicities. Timing, frequency, severity, as well as optimal management of CAR T-cell-related toxicities vary significantly between products and are likely to change as newer therapies become available. Currently the FDA approved CARs are targeted towards the B-cell malignancies however the future holds promise of expanding the target to solid tumor malignancies. Further highlighting the importance of early recognition and intervention for early and late onset CAR-T related toxicity. This contemporary review aims to describe presentation, grading and management of commonly encountered toxicities, short- and long-term complications, discuss preventive strategies and resource utilization.
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Affiliation(s)
- Simon R Mucha
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Prabalini Rajendram
- Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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15
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Myers RM, Shah NN, Pulsipher MA. How I use risk factors for success or failure of CD19 CAR T cells to guide management of children and AYA with B-cell ALL. Blood 2023; 141:1251-1264. [PMID: 36416729 PMCID: PMC10082355 DOI: 10.1182/blood.2022016937] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
By overcoming chemotherapeutic resistance, chimeric antigen receptor (CAR) T cells facilitate deep, complete remissions and offer the potential for long-term cure in a substantial fraction of patients with chemotherapy refractory disease. However, that success is tempered with 10% to 30% of patients not achieving remission and over half of patients treated eventually experiencing relapse. With over a decade of experience using CAR T cells in children, adolescents, and young adults (AYA) to treat relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) and 5 years since the first US Food and Drug Administration approval, data defining the nuances of patient-specific risk factors are emerging. With the commercial availability of 2 unique CD19 CAR T-cell constructs for B-ALL, in this article, we review the current literature, outline our approach to patients, and discuss how individual factors inform strategies to optimize outcomes in children and AYA receiving CD19 CAR T cells. We include data from both prospective and recent large retrospective studies that offer insight into understanding when the risks of CAR T-cell therapy failure are high and offer perspectives suggesting when consolidative hematopoietic cell transplantation or experimental CAR T-cell and/or alternative immunotherapy should be considered. We also propose areas where prospective trials addressing the optimal use of CAR T-cell therapy are needed.
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Affiliation(s)
- Regina M. Myers
- Division of Oncology, Cell Therapy and Transplant Section, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A. Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children’s Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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16
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Zhai X, Mao L, Wu M, Liu J, Yu S. Challenges of Anti-Mesothelin CAR-T-Cell Therapy. Cancers (Basel) 2023; 15:cancers15051357. [PMID: 36900151 PMCID: PMC10000068 DOI: 10.3390/cancers15051357] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/10/2023] [Accepted: 02/06/2023] [Indexed: 02/23/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T-cell therapy is a kind of adoptive T-cell therapy (ACT) that has developed rapidly in recent years. Mesothelin (MSLN) is a tumor-associated antigen (TAA) that is highly expressed in various solid tumors and is an important target antigen for the development of new immunotherapies for solid tumors. This article reviews the clinical research status, obstacles, advancements and challenges of anti-MSLN CAR-T-cell therapy. Clinical trials on anti-MSLN CAR-T cells show that they have a high safety profile but limited efficacy. At present, local administration and introduction of new modifications are being used to enhance proliferation and persistence and to improve the efficacy and safety of anti-MSLN CAR-T cells. A number of clinical and basic studies have shown that the curative effect of combining this therapy with standard therapy is significantly better than that of monotherapy.
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Affiliation(s)
- Xuejia Zhai
- Department of Stem Cell and Regenerative Medicine, Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Key Laboratory of Cancer Immunopathology, Ministry of Education, Chongqing 400038, China
- International Joint Research Center for Precision Biotherapy, Ministry of Science and Technology, Chongqing 400038, China
| | - Ling Mao
- Department of Stem Cell and Regenerative Medicine, Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Key Laboratory of Cancer Immunopathology, Ministry of Education, Chongqing 400038, China
- International Joint Research Center for Precision Biotherapy, Ministry of Science and Technology, Chongqing 400038, China
| | - Min Wu
- Department of Stem Cell and Regenerative Medicine, Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Key Laboratory of Cancer Immunopathology, Ministry of Education, Chongqing 400038, China
- International Joint Research Center for Precision Biotherapy, Ministry of Science and Technology, Chongqing 400038, China
| | - Jie Liu
- Department of Stem Cell and Regenerative Medicine, Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Key Laboratory of Cancer Immunopathology, Ministry of Education, Chongqing 400038, China
- International Joint Research Center for Precision Biotherapy, Ministry of Science and Technology, Chongqing 400038, China
| | - Shicang Yu
- Department of Stem Cell and Regenerative Medicine, Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Key Laboratory of Cancer Immunopathology, Ministry of Education, Chongqing 400038, China
- International Joint Research Center for Precision Biotherapy, Ministry of Science and Technology, Chongqing 400038, China
- Jinfeng Laboratory, Chongqing 401329, China
- Correspondence:
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17
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Butt OH, Zhou AY, Ances BM, DiPersio JF, Ghobadi A. A systematic framework for predictive biomarkers in immune effector cell-associated neurotoxicity syndrome. Front Neurol 2023; 14:1110647. [PMID: 36860569 PMCID: PMC9969296 DOI: 10.3389/fneur.2023.1110647] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/23/2023] [Indexed: 02/15/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy has revolutionized the management of several life-threatening malignancies, often achieving durable sustained responses. The number of patients treated with this new class of cell-based therapy, along with the number of Food and Drug Association (FDA) approved indications, are growing significantly. Unfortunately Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) can often occur after treatment with CAR-T cells, and severe ICANS can be associated with significant morbidity and mortality. Current standard treatments are mainly steroids and supportive care, highlighting the need for early identification. In the last several years, a range of predictive biomarkers have been proposed to distinguish patients at increased risk for developing ICANS. In this review, we discuss a systematic framework to organize potential predictive biomarkers that builds on our current understanding of ICANS.
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Affiliation(s)
- Omar H. Butt
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States,*Correspondence: Omar H. Butt ✉
| | - Alice Y. Zhou
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Beau M. Ances
- Department of Neurology, Washington University in Saint Louis, St. Louis, MO, United States
| | - John F. DiPersio
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
| | - Armin Ghobadi
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University in Saint Louis, St. Louis, MO, United States
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18
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Manriquez Roman C, Sakemura RL, Kimball BL, Jin F, Khadka RH, Adada MM, Siegler EL, Johnson AJ, Kenderian SS. Assessment of Chimeric Antigen Receptor T Cell-Associated Toxicities Using an Acute Lymphoblastic Leukemia Patient-derived Xenograft Mouse Model. J Vis Exp 2023:10.3791/64535. [PMID: 36847405 PMCID: PMC10600946 DOI: 10.3791/64535] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Chimeric antigen receptor T (CART) cell therapy has emerged as a powerful tool for the treatment of multiple types of CD19+ malignancies, which has led to the recent FDA approval of several CD19-targeted CART (CART19) cell therapies. However, CART cell therapy is associated with a unique set of toxicities that carry their own morbidity and mortality. This includes cytokine release syndrome (CRS) and neuroinflammation (NI). The use of preclinical mouse models has been crucial in the research and development of CART technology for assessing both CART efficacy and CART toxicity. The available preclinical models to test this adoptive cellular immunotherapy include syngeneic, xenograft, transgenic, and humanized mouse models. There is no single model that seamlessly mirrors the human immune system, and each model has strengths and weaknesses. This methods paper aims to describe a patient-derived xenograft model using leukemic blasts from patients with acute lymphoblastic leukemia as a strategy to assess CART19-associated toxicities, CRS, and NI. This model has been shown to recapitulate CART19-associated toxicities as well as therapeutic efficacy as seen in the clinic.
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Affiliation(s)
- Claudia Manriquez Roman
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester; Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester; Department of Molecular Medicine, Mayo Clinic, Rochester; Regenerative Sciences PhD Program, Mayo Clinic, Rochester
| | - R Leo Sakemura
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester
| | - Brooke L Kimball
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester
| | - Fang Jin
- Department of Immunology, Mayo Clinic, Rochester
| | | | - Mohamad M Adada
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester
| | - Elizabeth L Siegler
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester
| | | | - Saad S Kenderian
- T Cell Engineering Laboratory, Mayo Clinic, Rochester; Division of Hematology, Mayo Clinic, Rochester; Department of Immunology, Mayo Clinic, Rochester;
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19
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Saleh HA, Mitwasi N, Ullrich M, Kubeil M, Toussaint M, Deuther-Conrad W, Neuber C, Arndt C, R. Loureiro L, Kegler A, González Soto KE, Belter B, Rössig C, Pietzsch J, Frenz M, Bachmann M, Feldmann A. Specific and safe targeting of glioblastoma using switchable and logic-gated RevCAR T cells. Front Immunol 2023; 14:1166169. [PMID: 37122703 PMCID: PMC10145173 DOI: 10.3389/fimmu.2023.1166169] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Glioblastoma (GBM) is still an incurable tumor that is associated with high recurrence rate and poor survival despite the current treatment regimes. With the urgent need for novel therapeutic strategies, immunotherapies, especially chimeric antigen receptor (CAR)-expressing T cells, represent a promising approach for specific and effective targeting of GBM. However, CAR T cells can be associated with serious side effects. To overcome such limitation, we applied our switchable RevCAR system to target both the epidermal growth factor receptor (EGFR) and the disialoganglioside GD2, which are expressed in GBM. The RevCAR system is a modular platform that enables controllability, improves safety, specificity and flexibility. Briefly, it consists of RevCAR T cells having a peptide epitope as extracellular domain, and a bispecific target module (RevTM). The RevTM acts as a switch key that recognizes the RevCAR epitope and the tumor-associated antigen, and thereby activating the RevCAR T cells to kill the tumor cells. However, in the absence of the RevTM, the RevCAR T cells are switched off. In this study, we show that the novel EGFR/GD2-specific RevTMs can selectively activate RevCAR T cells to kill GBM cells. Moreover, we show that gated targeting of GBM is possible with our Dual-RevCAR T cells, which have their internal activation and co-stimulatory domains separated into two receptors. Therefore, a full activation of Dual-RevCAR T cells can only be achieved when both receptors recognize EGFR and GD2 simultaneously via RevTMs, leading to a significant killing of GBM cells both in vitro and in vivo.
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Affiliation(s)
- Haidy A. Saleh
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Nicola Mitwasi
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Martin Ullrich
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Manja Kubeil
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Magali Toussaint
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Winnie Deuther-Conrad
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Christin Neuber
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Claudia Arndt
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Faculty of Medicine Carl Gustav Carus, Mildred Scheel Early Career Center, Technische Universität Dresden, Dresden, Germany
| | - Liliana R. Loureiro
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Alexandra Kegler
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | | | - Birgit Belter
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
| | - Claudia Rössig
- Department of Pediatric Hematology and Oncology, University Children’s Hospital Münster, Münster, Germany
| | - Jens Pietzsch
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- Faculty of Chemistry and Food Chemistry, School of Science, Technische Universität Dresden, Dresden, Germany
| | - Marcus Frenz
- Faculty Informatik and Wirtschaftsinformatik, Provadis School of International Management and Technology AG, Frankfurt, Germany
| | - Michael Bachmann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- National Center for Tumor Diseases Dresden (NCT/UCC), German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site, Dresden, Germany
- *Correspondence: Michael Bachmann,
| | - Anja Feldmann
- Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiopharmaceutical Cancer Research, Dresden, Germany
- National Center for Tumor Diseases Dresden (NCT/UCC), German Cancer Research Center (DKFZ), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden-Rossendorf (HZDR), Dresden, Germany
- German Cancer Consortium (DKTK), Partner Site, Dresden, Germany
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20
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Chen X, Li P, Tian B, Kang X. Serious adverse events and coping strategies of CAR-T cells in the treatment of malignant tumors. Front Immunol 2022; 13:1079181. [PMID: 36569917 PMCID: PMC9772271 DOI: 10.3389/fimmu.2022.1079181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Chimeric antigen receptor T (CAR-T) cells technology has been successfully used in the treatment of B cell-derived hematological tumors and multiple myeloma. CAR-T cells are also being studied in a variety of solid tumors. Current clinical reports on CAR-T cells in the treatment of malignant tumors are abundant. The tumor-killing activity of CAR-T cells and the unique adverse effects of CAR-T cells have been confirmed by many studies. There is evidence that serious adverse events can be life-threatening. CAR-T cells therapy is increasingly used in clinical settings, so it is important to pay attention to its serious adverse events. In this review, we summarized the serious adverse events of CAR-T cells in the treatment of malignant tumors by reading literature and searching relevant clinical studies, and discussed the management and treatment of serious adverse events in an effort to provide theoretical support for clinicians who deal with such patients.
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21
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Hernani R, Benzaquén A, Solano C. Toxicities following CAR-T therapy for hematological malignancies. Cancer Treat Rev 2022; 111:102479. [DOI: 10.1016/j.ctrv.2022.102479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/25/2022]
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22
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Amidi Y, Eckhardt CA, Quadri SA, Malik P, Firme MS, Jones DK, Jain A, Danish HH, Rubin DB, Jacobson CA, Cash SS, Lee JW, Dietrich J, Westover MB. Forecasting immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor t-cell therapy. J Immunother Cancer 2022; 10:jitc-2022-005459. [PMID: 36450377 PMCID: PMC9716920 DOI: 10.1136/jitc-2022-005459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Immune effector cell-associated neurotoxicity syndrome (ICANS) is a clinical and neuropsychiatric syndrome that can occur days to weeks following administration chimeric antigen receptor (CAR) T-cell therapy. Manifestations of ICANS range from encephalopathy and aphasia to cerebral edema and death. Because the onset and time course of ICANS is currently unpredictable, prolonged hospitalization for close monitoring following CAR T-cell infusion is a frequent standard of care. METHODS This study was conducted at Brigham and Women's Hospital from April 2015 to February 2020. A cohort of 199 hospitalized patients treated with CAR T-cell therapy was used to develop a combined hidden Markov model and lasso-penalized logistic regression model to forecast the course of ICANS. Model development was done using leave-one-patient-out cross validation. RESULTS Among the 199 patients included in the analysis 133 were male (66.8%), and the mean (SD) age was 59.5 (11.8) years. 97 patients (48.7%) developed ICANS, of which 59 (29.6%) experienced severe grades 3-4 ICANS. Median time of ICANS onset was day 9. Selected clinical predictors included maximum daily temperature, C reactive protein, IL-6, and procalcitonin. The model correctly predicted which patients developed ICANS and severe ICANS, respectively, with area under the curve of 96.7% and 93.2% when predicting 5 days ahead, and area under the curve of 93.2% and 80.6% when predicting the entire future risk trajectory looking forward from day 5. Forecasting performance was also evaluated over time horizons ranging from 1 to 7 days, using metrics of forecast bias, mean absolute deviation, and weighted average percentage error. CONCLUSION The forecasting model accurately predicts risk of ICANS following CAR T-cell infusion and the time course ICANS follows once it has begun.Cite Now.
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Affiliation(s)
- Yalda Amidi
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Christine A Eckhardt
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Syed A Quadri
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Preeti Malik
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Marcos Santana Firme
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Daniel K Jones
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Aayushee Jain
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Husain H Danish
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Daniel B Rubin
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA,Cancer Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | | | - Sydney S Cash
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA
| | - Jong Woo Lee
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jorg Dietrich
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Brandon Westover
- Harvard Medical School, Boston, Massachusetts, USA,Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA,Clinical Data Animation Center (CDAC), Massachusetts General Hospital, Boston, MA, USA,Cancer Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
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23
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Li Y, Ming Y, Fu R, Li C, Wu Y, Jiang T, Li Z, Ni R, Li L, Su H, Liu Y. The pathogenesis, diagnosis, prevention, and treatment of CAR-T cell therapy-related adverse reactions. Front Pharmacol 2022; 13:950923. [PMID: 36313336 PMCID: PMC9616161 DOI: 10.3389/fphar.2022.950923] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR)-T cell therapy is effective in the treatment of refractory/relapsed (r/r) hematological malignancies (r/r B-cell lymphoblastic leukemia, B-cell lymphoma, and multiple myeloma). In addition, it is being explored as a treatment option for solid tumors. As of 31 March 2022, seven CAR-T therapies for hematological malignancies have been approved worldwide. Although CAR-T therapy is an effective treatment for many malignancies, it also causes adverse effects. The incidence of cytokine release syndrome (CRS), the most common adverse reaction after infusion of CAR-T cells, is as high as 93%.CRS, is the leading risk factor of immune effector cell-associated neurotoxicity syndrome (ICANS), as well as cardiovascular, hematological, hepatorenal, skin, pulmonary, and gastrointestinal toxicity. Severe adverse reactions complicated by CRS severely impede the widespread application of CAR-T therapy. The CAR-T product was initially approved in 2017; however, only limited studies have investigated the adverse reactions owing to CAR-T therapy compared to that of clinically approved drugs. Thus, we aimed to elucidate the mechanisms, risk factors, diagnostic criteria, and treatment of toxicities concurrent with CRS, thereby providing a valuable reference for the safe, effective, and widespread application of CAR-T therapy.
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24
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Zhang Z, Liu L, Ma C, Chen W. A Computational Model of Cytokine Release Syndrome during CAR T-cell Therapy. ADVANCED THERAPEUTICS 2022; 5:2200130. [PMID: 36590643 PMCID: PMC9797206 DOI: 10.1002/adtp.202200130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Indexed: 01/05/2023]
Abstract
Cytokine release syndrome (CRS) is a lethal adverse event in chimeric antigen receptor (CAR) T-cell therapy, hindering this promising therapy for cancers, such as B-cell acute lymphoblastic leukemia (B-ALL). Clinical management of CRS requires a better understanding of its underlying mechanisms. In this study, a computational model of CRS during CAR T-cell therapy is built to depict how the cellular interactions among CAR T-cells, B-ALL cells, and bystander monocytes, as well as the accompanying molecular interactions among various inflammatory cytokines, influence the severity of CRS. The model successfully defines the factors related to severe CRS and studied the effects of immunomodulatory therapy on CRS. The use of the model is also demonstrated as a precision medicine tool to optimize the treatment scheme, including personalized choice of CAR T-cell products and control of switchable CAR T-cell activity, for a more efficient and safer immunotherapy. This new computational oncology model can serve as a precision medicine tool to guide the clinical management of CRS during CAR T cell therapy.
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Affiliation(s)
- Zhuoyu Zhang
- Department of Mechanical and Aerospace Engineering, New York University, Brooklyn, NY 11201, USA
| | - Lunan Liu
- Department of Mechanical and Aerospace Engineering, New York University, Brooklyn, NY 11201, USA
| | - Chao Ma
- Department of Mechanical and Aerospace Engineering, New York University, Brooklyn, NY 11201, USA
| | - Weiqiang Chen
- Department of Mechanical and Aerospace Engineering, New York University, Brooklyn, NY 11201, USA
- Department of Biomedical Engineering, New York University, Brooklyn, NY 11201, USA
- Laura and Isaac Perlmutter Cancer Center, NYU Langone Health, New York, NY 10016, USA
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25
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Schofield HLT, Fabrizio VA, Braniecki S, Pelletier W, Eissa H, Murphy B, Chewning J, Barton KD, Embry LM, Levine JE, Schultz KR, Page KM. Monitoring Neurocognitive Functioning After Pediatric Cellular Therapy or Hematopoietic Cell Transplant: Guidelines From the COG Neurocognition in Cellular Therapies Task Force. Transplant Cell Ther 2022; 28:625-636. [PMID: 35870778 PMCID: PMC10167710 DOI: 10.1016/j.jtct.2022.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023]
Affiliation(s)
| | - Vanessa A Fabrizio
- Division of Bone Marrow Transplant and Cellular Therapy, University of Colorado, Boulder, Colorado
| | - Suzanne Braniecki
- Divisions of Pediatric Psychology and Hematology/Oncology, New York Medical College, New York, New York
| | - Wendy Pelletier
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Hesham Eissa
- Division of Bone Marrow Transplant and Cellular Therapy, University of Colorado, Boulder, Colorado
| | - Beverly Murphy
- Duke Medical Center Library & Archives, Duke University, Durham, North Carolina
| | - Joseph Chewning
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Karen D Barton
- Duke Medical Center Library & Archives, Duke University, Durham, North Carolina
| | - Leanne M Embry
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kirk R Schultz
- BC Children's Hospital and Research Institute, Vancouver, British Columbia, Canada
| | - Kristin M Page
- Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, Wisconsin
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26
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Gargett T, Ebert LM, Truong NTH, Kollis PM, Sedivakova K, Yu W, Yeo ECF, Wittwer NL, Gliddon BL, Tea MN, Ormsby R, Poonnoose S, Nowicki J, Vittorio O, Ziegler DS, Pitson SM, Brown MP. GD2-targeting CAR-T cells enhanced by transgenic IL-15 expression are an effective and clinically feasible therapy for glioblastoma. J Immunother Cancer 2022; 10:jitc-2022-005187. [PMID: 36167468 PMCID: PMC9516307 DOI: 10.1136/jitc-2022-005187] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 11/08/2022] Open
Abstract
Background Aggressive primary brain tumors such as glioblastoma are uniquely challenging to treat. The intracranial location poses barriers to therapy, and the potential for severe toxicity. Effective treatments for primary brain tumors are limited, and 5-year survival rates remain poor. Immune checkpoint inhibitor therapy has transformed treatment of some other cancers but has yet to significantly benefit patients with glioblastoma. Early phase trials of chimeric antigen receptor (CAR) T-cell therapy in patients with glioblastoma have demonstrated that this approach is safe and feasible, but with limited evidence of its effectiveness. The choices of appropriate target antigens for CAR-T-cell therapy also remain limited. Methods We profiled an extensive biobank of patients’ biopsy tissues and patient-derived early passage glioma neural stem cell lines for GD2 expression using immunomicroscopy and flow cytometry. We then employed an approved clinical manufacturing process to make CAR- T cells from patients with peripheral blood of glioblastoma and diffuse midline glioma and characterized their phenotype and function in vitro. Finally, we tested intravenously administered CAR-T cells in an aggressive intracranial xenograft model of glioblastoma and used multicolor flow cytometry, multicolor whole-tissue immunofluorescence and next-generation RNA sequencing to uncover markers associated with effective tumor control. Results Here we show that the tumor-associated antigen GD2 is highly and consistently expressed in primary glioblastoma tissue removed at surgery. Moreover, despite patients with glioblastoma having perturbations in their immune system, highly functional GD2-specific CAR-T cells can be produced from their peripheral T cells using an approved clinical manufacturing process. Finally, after intravenous administration, GD2-CAR-T cells effectively infiltrated the brain and controlled tumor growth in an aggressive orthotopic xenograft model of glioblastoma. Tumor control was further improved using CAR-T cells manufactured with a clinical retroviral vector encoding an interleukin-15 transgene alongside the GD2-specific CAR. These CAR-T cells achieved a striking 50% complete response rate by bioluminescence imaging in established intracranial tumors. Conclusions Targeting GD2 using a clinically deployed CAR-T-cell therapy has a sound scientific and clinical rationale as a treatment for glioblastoma and other aggressive primary brain tumors.
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Affiliation(s)
- Tessa Gargett
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia .,Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa M Ebert
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nga T H Truong
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Paris M Kollis
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kristyna Sedivakova
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Wenbo Yu
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia
| | - Erica C F Yeo
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia
| | - Nicole L Wittwer
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Briony L Gliddon
- Molecular Therapeutics Laboratory, Centre for Cancer Biology, Adelaide, South Australia, Australia
| | - Melinda N Tea
- Molecular Therapeutics Laboratory, Centre for Cancer Biology, Adelaide, South Australia, Australia
| | - Rebecca Ormsby
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Santosh Poonnoose
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Neurosurgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jake Nowicki
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Department of Neurosurgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Orazio Vittorio
- Children's Cancer Institute, Lowy Cancer Research Centre, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David S Ziegler
- Children's Cancer Institute, Lowy Cancer Research Centre, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Kid's Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Stuart M Pitson
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.,Molecular Therapeutics Laboratory, Centre for Cancer Biology, Adelaide, South Australia, Australia
| | - Michael P Brown
- Translational Oncology Laboratory, Centre for Cancer Biology, SA Pathology and Univeristy of South Australia, Adelaide, South Australia, Australia.,Cancer Clinical Trials Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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27
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Talleur AC, Myers R, Annesley C, Shalabi H. Chimeric Antigen Receptor T-cell Therapy: Current Status and Clinical Outcomes in Pediatric Hematologic Malignancies. Hematol Oncol Clin North Am 2022; 36:701-727. [PMID: 35780062 DOI: 10.1016/j.hoc.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Chimeric antigen receptor T-cell (CART) therapy has transformed the treatment paradigm for pediatric patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL), with complete remission rates in key pivotal CD19-CART trials ranging from 65% to 90%. Alongside this new therapy, new toxicity profiles and treatment limitations have emerged, necessitating toxicity consensus grading systems, cooperative group trials, and novel management approaches. This review highlights the results of key clinical trials of CART for pediatric hematologic malignancies, discusses the most common toxicities seen to date, and elucidates challenges, opportunities, and areas of active research to optimize this therapy.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, 262 Danny Thomas Place, MS1130, Memphis, TN 38105, USA
| | - Regina Myers
- Division of Oncology, Children's Hospital of Philadelphia, Office 2568A, 3500 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, 4800 Sand Point Way NE, M/S MB8.501, Seattle, WA 98145-5005, USA
| | - Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Building 10, Room 1W-5750, 9000 Rockville Pike, Bethesda, MD 20892-1104, USA.
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28
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Schroeder BA, Jess J, Sankaran H, Shah NN. Clinical trials for chimeric antigen receptor T-cell therapy: lessons learned and future directions. Curr Opin Hematol 2022; 29:225-232. [PMID: 35787551 PMCID: PMC9354650 DOI: 10.1097/moh.0000000000000723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the status and utilization of chimeric antigen receptor T-cell (CAR-T) therapy based on the most recent clinical trials in patients with leukemia and lymphoma. Additionally, this review will highlight limitations in current strategies, discuss efforts in toxicity mitigation, and outline future directions for investigation. RECENT FINDINGS CD19 targeted CAR-T-cell therapy (CD19-CAR) is highly effective in patients with relapsed/refractory (r/r) B-cell hematologic malignancies. However, multiple challenges have arisen, particularly life-threatening adverse events, such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome. Despite these challenges, recent CD19-CAR trials, including two randomized studies, have demonstrated both impressive initial results along with durable responses. Combined with results emerging from 'real-world' experience, the efficacy of CAR-T-cells is high, propelling CAR-T-cells studies targeting alternate B-cell antigens [e.g. CD20, CD22 and CD269 (BCMA)] and other targets for hematologic malignancies, along with solid and CNS tumors. SUMMARY Given the benefit for CD19-CAR, determining the appropriate place in utilization for both an individual patient's treatment course and more broadly in the generalized treatment paradigm is critically needed. We discuss the most recent trials exploring this topic and future directions in the field.
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Affiliation(s)
- Brett A. Schroeder
- National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Jennifer Jess
- Pediatric Oncology Branch, Center for Cancer Research (CCR), NCI, NIH, Bethesda, MD
| | - Hari Sankaran
- Biometric Research Program, Division of Cancer Treatment and Diagnosis, NCI, NIH, Bethesda, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), NCI, NIH, Bethesda, MD
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29
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Lv M, Liu Y, Liu W, Xing Y, Zhang S. Immunotherapy for Pediatric Acute Lymphoblastic Leukemia: Recent Advances and Future Perspectives. Front Immunol 2022; 13:921894. [PMID: 35769486 PMCID: PMC9234114 DOI: 10.3389/fimmu.2022.921894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 05/19/2022] [Indexed: 11/13/2022] Open
Abstract
Pediatric acute lymphoblastic leukemia (ALL) is the most common subtype of childhood leukemia, which is characterized by the abnormal proliferation and accumulation of immature lymphoid cell in the bone marrow. Although the long-term survival rate for pediatric ALL has made significant progress over years with the development of contemporary therapeutic regimens, patients are still suffered from relapse, leading to an unsatisfactory outcome. Since the immune system played an important role in the progression and relapse of ALL, immunotherapy including bispecific T-cell engagers and chimeric antigen receptor T cells has been demonstrated to be capable of enhancing the immune response in pediatric patients with refractory or relapsed B-cell ALL, and improving the cure rate of the disease and patients’ quality of life, thus receiving the authorization for market. Nevertheless, the resistance and toxicities associated with the current immunotherapy remains a huge challenge. Novel therapeutic options to overcome the above disadvantages should be further explored. In this review, we will thoroughly discuss the emerging immunotherapeutics for the treatment of pediatric ALL, as well as side-effects and new development.
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Affiliation(s)
- Meng Lv
- Department of Pharmacy, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yan Liu
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Liu
- Department of Hematology Oncology, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Yabing Xing
- Department of Pharmacy, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- *Correspondence: Yabing Xing, ; Shengnan Zhang,
| | - Shengnan Zhang
- Department of Pharmacy, Children’s Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- *Correspondence: Yabing Xing, ; Shengnan Zhang,
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Wang J, Zhang X, Zhou Z, Liu Y, Yu L, Jia L, Yang J, Li J, Yu H, Li W, Liu G, Rui W, Zheng H, Zhao X, Lin X, Lu P. A novel adoptive synthetic TCR and antigen receptor (STAR) T-Cell therapy for B-Cell acute lymphoblastic leukemia. Am J Hematol 2022; 97:992-1004. [PMID: 35491511 DOI: 10.1002/ajh.26586] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 01/24/2023]
Abstract
We developed a T-cell-receptor (TCR) complex-based chimeric antigen receptor (CAR) named Synthetic TCR and Antigen Receptor (STAR). Here, we report pre-clinical and phase I clinical trial data (NCT03953599) of this T-cell therapy for refractory and relapsed (R/R) B-cell acute lymphoblastic leukemia (B-ALL) patients. STAR consists of two protein modules each containing an antibody light or heavy chain variable region and TCR α or β chain constant region fused to the co-stimulatory domain of OX40. T-cells were transduced with a STAR-OX40 lentiviral vector. A leukemia xenograft mouse model was used to assess the STAR/STAR-OX40 T cell antitumor activity. Eighteen patients with R/R B-ALL were enrolled into the clinical trial. In a xenograft mouse model, STAR-T-cells exhibited superior tumor-specific cytotoxicity compared with conventional CAR-T cells. Incorporating OX40 into STAR further improved the proliferation and persistence of tumor-targeting T-cells. In our clinical trial, 100% of patients achieved complete remission 4 weeks post-STAR-OX40 T-cell infusion and 16/18 (88.9%) patients pursued consolidative allogeneic hematopoietic stem cell transplantation (allo-HSCT). Twelve of 16 patients (75%) remained leukemia-free after a median follow-up of 545 (433-665) days. The two patients without consolidative allo-HSCT relapsed on Day 58 and Day 186. Mild cytokine release syndrome occurred in 10/18 (55.6%) patients, and 2 patients experienced grade III neurotoxicity. Our preclinical studies demonstrate super anti-tumor potency of STAR-OX40 T-cells compared with conventional CAR-T cells. The first-in-human clinical trial shows that STAR-OX40 T-cells are tolerable and an effective therapeutic platform for treating R/R B-ALL.
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Affiliation(s)
- Jiasheng Wang
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
- Tsinghua‐Peking Center for Life Sciences Beijing China
| | - Xian Zhang
- Hebei Yanda Lu Daopei Hospital Langfang China
- Lu Daopei Institute of Hematology Beijing China
| | - Zhixiao Zhou
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Yue Liu
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Li Yu
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Lemei Jia
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Junfang Yang
- Hebei Yanda Lu Daopei Hospital Langfang China
- Lu Daopei Institute of Hematology Beijing China
| | - Jingjing Li
- Hebei Yanda Lu Daopei Hospital Langfang China
- Lu Daopei Institute of Hematology Beijing China
| | - Hanyang Yu
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Wenzhong Li
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Guangna Liu
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
| | - Wei Rui
- China Immunotech Biotechnology Co. Ltd. Beijing China
| | - Hongli Zheng
- China Immunotech Biotechnology Co. Ltd. Beijing China
| | - Xueqiang Zhao
- China Immunotech Biotechnology Co. Ltd. Beijing China
| | - Xin Lin
- Department of Basic Medical Sciences Tsinghua University School of Medicine Beijing China
- Tsinghua‐Peking Center for Life Sciences Beijing China
| | - Peihua Lu
- Hebei Yanda Lu Daopei Hospital Langfang China
- Lu Daopei Institute of Hematology Beijing China
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Shalabi H, Nellan A, Shah NN, Gust J. Immunotherapy Associated Neurotoxicity in Pediatric Oncology. Front Oncol 2022; 12:836452. [PMID: 35265526 PMCID: PMC8899040 DOI: 10.3389/fonc.2022.836452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/20/2022] [Indexed: 11/30/2022] Open
Abstract
Novel immunotherapies are increasingly being employed in pediatric oncology, both in the upfront and relapsed/refractory settings. Through various mechanisms of action, engagement and activation of the immune system can cause both generalized and disease site-specific inflammation, leading to immune-related adverse events (irAEs). One of the most worrisome irAEs is that of neurotoxicity. This can present as a large spectrum of neurological toxicities, including confusion, aphasia, neuropathies, seizures, and/or death, with variable onset and severity. Earlier identification and treatment, generally with corticosteroids, remains the mainstay of neurotoxicity management to optimize patient outcomes. The pathophysiology of neurotoxicity varies across the different therapeutic strategies and remains to be elucidated in most cases. Furthermore, little is known about long-term neurologic sequelae. This review will focus on neurotoxicity seen with the most common immunotherapies used in pediatric oncology, including CAR T cell therapy, alternative forms of adoptive cell therapy, antibody therapies, immune checkpoint inhibitors, and tumor vaccines. Herein we will discuss the incidence, pathophysiology, symptomatology, diagnosis, and management strategies currently being utilized for immunotherapy-associated neurotoxicity with a focus on pediatric specific considerations.
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Affiliation(s)
- Haneen Shalabi
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Anandani Nellan
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Nirali N Shah
- National Cancer Institute, Pediatric Oncology Branch, National Institutes of Health, Bethesda, MD, United States
| | - Juliane Gust
- Seattle Children's Research Institute, Seattle, WA, United States.,Department of Neurology, University of Washington, Seattle, WA, United States
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Grant SJ, Grimshaw AA, Silberstein J, Murdaugh D, Wildes TM, E Rosko A, Giri S. Clinical presentation, risk factors, and outcomes of immune effector cell-associated neurotoxicity syndrome following CAR-T cell therapy: A Systematic Review. Transplant Cell Ther 2022; 28:294-302. [DOI: 10.1016/j.jtct.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/26/2022] [Accepted: 03/07/2022] [Indexed: 12/11/2022]
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Shalabi H, Martin S, Yates B, Wolters PL, Kaplan C, Smith H, Sesi CR, Jess J, Toledo-Tamula MA, Struemph K, Delbrook CP, Khan OI, Mackall CL, Lee DW, Shah NN. Neurotoxicity following CD19/CD28ζ CAR T-cells in children and young adults with B-cell malignancies. Neuro Oncol 2022; 24:1584-1597. [PMID: 35148417 PMCID: PMC9435493 DOI: 10.1093/neuonc/noac034] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neurotoxicity is an established toxicity of CD19 CAR T-cell therapy; however, there is little information on neurotoxicity in children, adolescents, and young adults (CAYA) receiving CD19/CD28ζ CAR T-cells for B-cell malignancies. METHODS We analyzed neurotoxicity of CD19/CD28ζ CAR T-cells in CAYA treated on a phase I study (NCT01593696). Assessments included daily inpatient monitoring, caregiver-based neuro-symptom checklist (NSC), exploratory neurocognitive assessments, clinically-indicated imaging, CSF analysis, and systematic cytokine profiling, outcomes of which were associated with cytokine release syndrome (CRS) and treatment response postinfusion. Patients with active CNS leukemia were included. RESULTS Amongst 52 patients treated, 13 patients had active CNS leukemia at infusion. Neurotoxicity was seen in 11/52 (21.2%) patients, with an incidence of 29.7% (11/37) in patients with CRS. Neurotoxicity was associated with the presence and severity of CRS. Those with neurotoxicity had higher levels of peak serum IL-6, IFNγ, and IL-15. Additionally, CNS leukemia was effectively eradicated in most patients with CRS. Pilot neurocognitive testing demonstrated stable-to-improved neurocognitive test scores in most patients, albeit limited by small patient numbers. The NSC enabled caregiver input into the patient experience. CONCLUSIONS This is the first systematic analysis of neurotoxicity utilizing a CD19/CD28ζ CAR construct in CAYA, including in those with active CNS involvement. The experience demonstrates that the neurotoxicity profile was acceptable and reversible, with evidence of anti-leukemia response and CNS trafficking of CAR T-cells. Additionally, neurocognitive testing, while exploratory, provides an opportunity for future studies to employ systematic evaluations into neurotoxicity assessments and validation is needed in future studies.
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Affiliation(s)
- Haneen Shalabi
- Corresponding Author: Haneen Shalabi, DO, Pediatric Oncology Branch, National Cancer Institute, National Institutes of Health, Building 10, Room 1W-5750, 9000 Rockville Pike, Bethesda, MD 20892-1104, USA ()
| | | | - Bonnie Yates
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Claire Kaplan
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Hannah Smith
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Christopher R Sesi
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Jennifer Jess
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Mary Anne Toledo-Tamula
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD, USA
| | - Kari Struemph
- Clinical Research Directorate, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick, MD, USA
| | - Cindy P Delbrook
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
| | - Omar I Khan
- National Institutes of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Crystal L Mackall
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA,Center for Cancer Cell Therapy, Stanford Cancer Institute, Palo Alto, California, USA,Department of Pediatrics, Stanford University, Palo Alto, California, USA,Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Daniel W Lee
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA,Department of Pediatric Hematology/Oncology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA,University of Virginia Cancer Center, Charlottesville, Virginia, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland, USA
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Insights into Modern Therapeutic Approaches in Pediatric Acute Leukemias. Cells 2022; 11:cells11010139. [PMID: 35011701 PMCID: PMC8749975 DOI: 10.3390/cells11010139] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/07/2021] [Accepted: 12/15/2021] [Indexed: 02/01/2023] Open
Abstract
Pediatric cancers predominantly constitute lymphomas and leukemias. Recently, our knowledge and awareness about genetic diversities, and their consequences in these diseases, have greatly expanded. Modern solutions are focused on mobilizing and impacting a patient’s immune system. Strategies to stimulate the immune system, to prime an antitumor response, are of intense interest. Amid those types of therapies are chimeric antigen receptor T (CAR-T) cells, bispecific antibodies, and antibody–drug conjugates (ADC), which have already been approved in the treatment of acute lymphoblastic leukemia (ALL)/acute myeloid leukemia (AML). In addition, immune checkpoint inhibitors (ICIs), the pattern recognition receptors (PRRs), i.e., NOD-like receptors (NLRs), Toll-like receptors (TLRs), and several kinds of therapy antibodies are well on their way to showing significant benefits for patients with these diseases. This review summarizes the current knowledge of modern methods used in selected pediatric malignancies and presents therapies that may hold promise for the future.
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Gu T, Hu K, Si X, Hu Y, Huang H. Mechanisms of immune effector cell-associated neurotoxicity syndrome after CAR-T treatment. WIREs Mech Dis 2022; 14:e1576. [PMID: 35871757 PMCID: PMC9787013 DOI: 10.1002/wsbm.1576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 06/05/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
Chimeric antigen receptor T-cell (CAR-T) treatment has revolutionized the landscape of cancer therapy with significant efficacy on hematologic malignancy, especially in relapsed and refractory B cell malignancies. However, unexpected serious toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS) still hamper its broad application. Clinical trials using CAR-T cells targeting specific antigens on tumor cell surface have provided valuable information about the characteristics of ICANS. With unclear mechanism of ICANS after CAR-T treatment, unremitting efforts have been devoted to further exploration. Clinical findings from patients with ICANS strongly indicated existence of overactivated peripheral immune response followed by endothelial activation-induced blood-brain barrier (BBB) dysfunction, which triggers subsequent central nervous system (CNS) inflammation and neurotoxicity. Several animal models have been built but failed to fully replicate the whole spectrum of ICANS in human. Hopefully, novel and powerful technologies like single-cell analysis may help decipher the precise cellular response within CNS from a different perspective when ICANS happens. Moreover, multidisciplinary cooperation among the subjects of immunology, hematology, and neurology will facilitate better understanding about the complex immune interaction between the peripheral, protective barriers, and CNS in ICANS. This review elaborates recent findings about ICANS after CAR-T treatment from bed to bench, and discusses the potential cellular and molecular mechanisms that may promote effective management in the future. This article is categorized under: Cancer > Biomedical Engineering Immune System Diseases > Molecular and Cellular Physiology Neurological Diseases > Molecular and Cellular Physiology.
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Affiliation(s)
- Tianning Gu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Kejia Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Xiaohui Si
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - Yongxian Hu
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
| | - He Huang
- Bone Marrow Transplantation Centerthe First Affiliated Hospital, Zhejiang University School of MedicineHangzhouZhejiang310003China,Liangzhu LaboratoryZhejiang University Medical CenterHangzhouChina,Institute of HematologyZhejiang UniversityHangzhou310058China,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity TherapyHangzhouChina
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Bhojwani D. Managing therapy-associated neurotoxicity in children with ALL. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:376-383. [PMID: 34889354 PMCID: PMC8791096 DOI: 10.1182/hematology.2021000269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Several chemotherapeutic agents and novel immunotherapies provide excellent control of systemic and central nervous system (CNS) leukemia but can be highly neurotoxic. The manifestations of subacute methotrexate neurotoxicity are diverse and require vigilant management; nonetheless, symptoms are transient in almost all patients. As methotrexate is a crucial drug to prevent CNS relapse, it is important to aim to resume it after full neurologic recovery. Most children tolerate methotrexate rechallenge without significant delays or prophylactic medications. Neurotoxicity is more frequent with newer immunotherapies such as CD19- chimeric antigen receptor T (CAR T) cells and blinatumomab. A uniform grading system for immune effector cell-associated neurotoxicity syndrome (ICANS) and algorithms for management based on severity have been developed. Low-grade ICANS usually resolves within a few days with supportive measures, but severe ICANS requires multispecialty care in the intensive care unit for life-threatening seizures and cerebral edema. Pharmacologic interventions include anticonvulsants for seizure control and glucocorticoids to reduce neuroinflammation. Anticytokine therapies targeted to the pathophysiology of ICANS are in development. By using illustrative patient cases, we discuss the management of neurotoxicity from methotrexate, CAR T cells, and blinatumomab in this review.
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Affiliation(s)
- Deepa Bhojwani
- Division of Hematology-Oncology, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
- Correspondence Deepa Bhojwani, MD, Division of Hematology-Oncology, Children’s Hospital Los Angeles, 4650 Sunset Blvd., MS 54, Los Angeles, CA 90027;
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Xiao X, Huang S, Chen S, Wang Y, Sun Q, Xu X, Li Y. Mechanisms of cytokine release syndrome and neurotoxicity of CAR T-cell therapy and associated prevention and management strategies. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:367. [PMID: 34794490 PMCID: PMC8600921 DOI: 10.1186/s13046-021-02148-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/20/2021] [Indexed: 02/08/2023]
Abstract
Chimeric antigen receptor (CAR) T-cell therapy has yielded impressive outcomes and transformed treatment algorithms for hematological malignancies. To date, five CAR T-cell products have been approved by the US Food and Drug Administration (FDA). Nevertheless, some significant toxicities pose great challenges to the development of CAR T-cell therapy, most notably cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). Understanding the mechanisms underlying these toxicities and establishing prevention and treatment strategies are important. In this review, we summarize the mechanisms underlying CRS and ICANS and provide potential treatment and prevention strategies.
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Affiliation(s)
- Xinyi Xiao
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Shengkang Huang
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Sifei Chen
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China
| | - Yazhuo Wang
- The Second School of Clinical Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China.,Medical College of Rehabilitation, Southern Medical University, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Qihang Sun
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, 510623, People's Republic of China
| | - Xinjie Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, People's Republic of China.
| | - Yuhua Li
- Department of Hematology, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, People's Republic of China. .,Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, Guangdong, 510005, People's Republic of China.
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Leahy AB, Newman H, Li Y, Liu H, Myers R, DiNofia A, Dolan JG, Callahan C, Baniewicz D, Devine K, Wray L, Aplenc R, June CH, Grupp SA, Rheingold SR, Maude SL. CD19-targeted chimeric antigen receptor T-cell therapy for CNS relapsed or refractory acute lymphocytic leukaemia: a post-hoc analysis of pooled data from five clinical trials. Lancet Haematol 2021; 8:e711-e722. [PMID: 34560014 PMCID: PMC9026766 DOI: 10.1016/s2352-3026(21)00238-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/26/2021] [Accepted: 07/29/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND CNS relapse of acute lymphocytic leukaemia is difficult to treat. Durable remissions of relapsed or refractory B-cell acute lymphocytic leukaemia have been observed following treatment with CD19-directed chimeric antigen receptor (CAR) T cells; however, most trials have excluded patients with active CNS disease. We aimed to assess the safety and activity of CAR T-cell therapy in patients with a history of CNS relapsed or refractory B-cell acute lymphocytic leukaemia. METHODS In this post-hoc analysis, we included 195 patients (aged 1-29 years; 110 [56%] male and 85 [44%] female) with relapsed or refractory CD19-positive acute lymphocytic leukaemia or lymphocytic lymphoma from five clinical trials (Pedi CART19, 13BT022, ENSIGN, ELIANA, and 16CT022) done at the Children's Hospital of Philadelphia (Philadelphia, PA, USA), in which participants received CD19-directed CAR T-cell therapy between April 17, 2012, and April 16, 2019. The trials required control of CNS disease at enrolment and infusion and excluded treatment in the setting of acute neurological toxic effects (>grade 1 in severity) or parenchymal lesions deemed to increase the risk of neurotoxicity. 154 patients from Pedi CART19, ELIANA, ENSIGN, and 16CT022 received tisagenlecleucel and 41 patients from the 13BT022 trial received the humanised CD19-directed CAR, huCART19. We categorised patients into two strata on the basis of CNS status at relapse or within the 12 months preceding CAR T-cell infusion-either CNS-positive or CNS-negative disease. Patients with CNS-positive disease were further divided on the basis of morphological bone marrow involvement-either combined bone marrow and CNS involvement, or isolated CNS involvement. Endpoints were the proportion of patients with complete response at 28 days after infusion, Kaplan-Meier analysis of relapse-free survival and overall survival, and the incidence of cytokine release syndrome and neurotoxicity. FINDINGS Of all 195 patients, 66 (34%) were categorised as having CNS-positive disease and 129 (66%) as having CNS-negative disease, and 43 (22%) were categorised as having isolated CNS involvement. The median length of follow-up was 39 months (IQR 25-49) in the CNS-positive stratum and 36 months (18-49) in the CNS-negative stratum. The proportion of patients in the CNS-positive stratum with a complete response at 28 days after infusion was similar to that in the CNS-negative stratum (64 [97%] of 66 vs 121 [94%] of 129; p=0·74), with no significant difference in relapse-free survival (60% [95% CI 49-74] vs 60% [51-71]; p=0·50) or overall survival (83% [75-93] vs 71% [64-79]; p=0·39) at 2 years between the two groups. Overall survival at 2 years was significantly higher in patients with isolated CNS involvement compared with those with bone marrow involvement (91% [82-100] vs 71% [64-78]; p=0·046). The incidence and severity of neurotoxicity (any grade, 53 [41%] vs 38 [58%]; grade 1, 24 [19%] vs 20 [30%]; grade 2, 14 [11%] vs 10 [15%]; grade 3, 12 [9%] vs 6 [9%], and grade 4, 3 [2%] vs 2 [3%]; p=0·20) and cytokine release syndrome (any grade, 110 [85%] vs 53 [80%]; grade 1, 12 [9%] vs 2 [3%]; grade 2, 61 [47%] vs 38 [58%]; grade 3, 18 [14%] vs 7 [11%] and grade 4, 19 [15%] vs 6 [9%]; p=0·26) did not differ between the CNS-negative and the CNS-positive disease strata. INTERPRETATION Tisagenlecleucel and huCART19 are active at clearing CNS disease and maintaining durable remissions in children and young adults with CNS relapsed or refractory B-cell acute lymphocytic leukaemia or lymphocytic lymphoma, without increasing the risk of severe neurotoxicity; although care should be taken in the timing of therapy and disease control to mitigate this risk. These preliminary findings support the use of these CAR T-cell therapies for patients with CNS relapsed or refractory B-cell acute lymphocytic leukaemia. FUNDING Children's Hospital of Philadelphia Frontier Program.
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Affiliation(s)
- Allison Barz Leahy
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Penn Center for Cancer Care Innovation, University of Pennsylvania, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Haley Newman
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yimei Li
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Hongyan Liu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Regina Myers
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Amanda DiNofia
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joseph G Dolan
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Colleen Callahan
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diane Baniewicz
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kaitlin Devine
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lisa Wray
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Richard Aplenc
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Carl H June
- Center for Cellular Immunotherapies, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; The Parker Institute for Cancer Immunotherapy, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stephan A Grupp
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Susan R Rheingold
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shannon L Maude
- Division of Oncology and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Cellular Immunotherapies, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Castaneda-Puglianini O, Chavez JC. Assessing and Management of Neurotoxicity After CAR-T Therapy in Diffuse Large B-Cell Lymphoma. J Blood Med 2021; 12:775-783. [PMID: 34466048 PMCID: PMC8403007 DOI: 10.2147/jbm.s281247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/31/2021] [Indexed: 11/23/2022] Open
Abstract
Chimeric antigen receptor T-cell (CAR-T) therapy represents the most important advances in cancer immunotherapy, especially in hematological malignancies such as B-cell lymphomas. CAR-T cell therapy has significant activity in poor risk B-cell lymphomas. CAR-T cell therapy is associated with potentially life-threatening toxicities such as cytokine release syndrome (CRS) and neurotoxicity (NT). While CRS pathophysiology and management are well established, the understanding and treatment of NT continues to develop. All current CAR-T products approved for DLBCL have been associated with NT with some differences in their severity. As cell therapies continue to advance and its access broadening, it will be imperative for clinicians to be aware of the signs and symptoms of NT, its stratification and basic management.
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Affiliation(s)
- Omar Castaneda-Puglianini
- Virginia Commonwealth University, Massey Cancer Center, Cellular Immunotherapies and Transplant Program, Richmond, VA, USA
| | - Julio C Chavez
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL, USA
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Si Lim SJ, Grupp SA, DiNofia AM. Tisagenlecleucel for treatment of children and young adults with relapsed/refractory B-cell acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29123. [PMID: 34061452 DOI: 10.1002/pbc.29123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 04/20/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022]
Abstract
The treatment landscape for cancer therapy has changed drastically over the past decade. Tisagenlecleucel, the first genetically engineered adoptive cellular therapy approved by the United States Food and Drug Administration, has revolutionized this field by demonstrating impressive clinical success in children and young adults with relapsed/refractory B-cell acute lymphoblastic leukemia (r/r B-ALL). Now 3 years since its approval, we have gained a deeper understanding on the basic immunobiology and clinical efficacy of this drug. This review will provide an updated summary of tisagenlecleucel in childhood and young adults with r/r B-ALL, common side effects and their associated management strategies, as well as barriers that remain to be addressed in order to realize the maximum potential of this drug.
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Affiliation(s)
- Stephanie J Si Lim
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Pediatric Oncology-Hematology, University of Hawai'i Cancer Center, Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii, USA.,Department of Pediatrics, University of Hawai'i School of Medicine, Honolulu, Hawaii, USA
| | - Stephen A Grupp
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amanda M DiNofia
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Bücklein V, Blumenberg V, Subklewe M. [Practical aspects of the application of CAR T cells and management of their toxicities]. Dtsch Med Wochenschr 2021; 146:1129-1137. [PMID: 34448189 DOI: 10.1055/a-1303-8708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CD19 CAR T cells induce - in part long-lasting - remissions in heavily pretreated patients with relapsed/refractory B-cell malignancies. However, they are associated with unique toxicities, and patient management therefore requires specific expertise.In this review, we outline the basics of their mode of action and present the currently available data on their efficacy in various B-cell and plasma cell malignancies. Currently approved therapies (Tisagenlecleucel, Axicabtagene ciloleucel, Brexucabtagene autoleucel) for patients are outlined as well as indications where approvals are expected in the near future. We discuss practical aspects of CAR T cell therapy from the patient's initial presentation, over leukapheresis, to CAR T cell transfusion. Additionally, we highlight the pathophysiology and principles of the management of the most common toxicities (cytokine release syndrome [CRS], immune cell associated neurotoxicity syndrome [ICANS] and cytopenias).
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Levine JE, Grupp SA, Pulsipher MA, Dietz AC, Rives S, Myers GD, August KJ, Verneris MR, Buechner J, Laetsch TW, Bittencourt H, Baruchel A, Boyer MW, De Moerloose B, Qayed M, Davies SM, Phillips CL, Driscoll TA, Bader P, Schlis K, Wood PA, Mody R, Yi L, Leung M, Eldjerou LK, June CH, Maude SL. Pooled safety analysis of tisagenlecleucel in children and young adults with B cell acute lymphoblastic leukemia. J Immunother Cancer 2021; 9:e002287. [PMID: 34353848 PMCID: PMC8344270 DOI: 10.1136/jitc-2020-002287] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Tisagenlecleucel, an anti-CD19 chimeric antigen receptor T cell therapy, has demonstrated efficacy in children and young adults with relapsed/refractory B cell acute lymphoblastic leukemia (B-ALL) in two multicenter phase 2 trials (ClinicalTrials.gov, NCT02435849 (ELIANA) and NCT02228096 (ENSIGN)), leading to commercialization of tisagenlecleucel for the treatment of patients up to age 25 years with B-ALL that is refractory or in second or greater relapse. METHODS A pooled analysis of 137 patients from these trials (ELIANA: n=79; ENSIGN: n=58) was performed to provide a comprehensive safety profile for tisagenlecleucel. RESULTS Grade 3/4 tisagenlecleucel-related adverse events (AEs) were reported in 77% of patients. Specific AEs of interest that occurred ≤8 weeks postinfusion included cytokine-release syndrome (CRS; 79% (grade 4: 22%)), infections (42%; grade 3/4: 19%), prolonged (not resolved by day 28) cytopenias (40%; grade 3/4: 34%), neurologic events (36%; grade 3: 10%; no grade 4 events), and tumor lysis syndrome (4%; all grade 3). Treatment for CRS included tocilizumab (40%) and corticosteroids (23%). The frequency of neurologic events increased with CRS severity (p<0.001). Median time to resolution of grade 3/4 cytopenias to grade ≤2 was 2.0 (95% CI 1.87 to 2.23) months for neutropenia, 2.4 (95% CI 1.97 to 3.68) months for lymphopenia, 2.0 (95% CI 1.87 to 2.27) months for leukopenia, 1.9 (95% CI 1.74 to 2.10) months for thrombocytopenia, and 1.0 (95% CI 0.95 to 1.87) month for anemia. All patients who achieved complete remission (CR)/CR with incomplete hematologic recovery experienced B cell aplasia; however, as nearly all responders also received immunoglobulin replacement, few grade 3/4 infections occurred >1 year postinfusion. CONCLUSIONS This pooled analysis provides a detailed safety profile for tisagenlecleucel during the course of clinical trials, and AE management guidance, with a longer follow-up duration compared with previous reports.
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Affiliation(s)
- John E Levine
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stephan A Grupp
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael A Pulsipher
- Section of Transplantation and Cellular Therapy, Children's Hospital Los Angeles Cancer and Blood Disease Institute, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Andrew C Dietz
- Section of Transplantation and Cellular Therapy, Children's Hospital Los Angeles Cancer and Blood Disease Institute, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Susana Rives
- Department of Pediatric Hematology and Oncology, Hospital Sant Joan de Déu de Barcelona, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - G Douglas Myers
- Children's Mercy Hospital Kansas City, Kansas City, Missouri, USA
| | - Keith J August
- Children's Mercy Hospital Kansas City, Kansas City, Missouri, USA
| | - Michael R Verneris
- Division of Pediatric Blood and Marrow Transplant, University of Minnesota, Minneapolis, Minnesota, USA
- Department of BMT and Cellular Therapy, Children's Hospital Colorado, University of Colorado, Boulder, Colorado, USA
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Theodore W Laetsch
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics and Harold C. Simmons Comprehensive Cancer Center, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Pauline Allen Gill Center for Cancer and Blood Disorders, Children's Health, Dallas, Texas, USA
| | - Henrique Bittencourt
- Hematology Oncology Division, Charles-Bruneau Cancer Center, CHU Sainte-Justine, Montreal, Québec, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, Québec, Canada
| | - Andre Baruchel
- Pediatric Hematology-Immunology Department, University Hospital Robert Debré (APHP) and Université de Paris, Paris, France
| | - Michael W Boyer
- Department of Pediatrics and Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University, Atlanta, Georgia, USA
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christine L Phillips
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
- Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Timothy A Driscoll
- Department of Pediatric Transplant and Cellular Therapy, Children's Health Center, Duke University Medical Center, Durham, North Carolina, USA
| | - Peter Bader
- Division for Stem Cell Transplantation and Immunology, Hospital for Children and Adolescents, University Hospital Frankfurt, Frankfurt, Germany
| | - Krysta Schlis
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Patricia A Wood
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Rajen Mody
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Lan Yi
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Mimi Leung
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Lamis K Eldjerou
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Carl H June
- Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shannon L Maude
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Oncology, Center for Childhood Cancer Research and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Beuchat I, Danish H, Rubin DB, Jacobson C, Robertson M, Vaitkevicius H, Lee JW. EEG findings in CART T associated neurotoxicity: clinical and radiological correlations. Neuro Oncol 2021; 24:313-325. [PMID: 34265061 DOI: 10.1093/neuonc/noab174] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND While EEG is frequently reported as abnormal after CAR T cell therapy, its clinical significance remains unclear. We aim to systematically describe EEG features in a large single-center cohort and correlate them with clinical and radiological findings. METHODS We retrospectively identified patients undergoing CAR T cell therapy who had continuous EEG. Neurotoxicity grades, detailed neurological symptoms, and brain MRI or FDG-PET were obtained. Correlation between clinical and radiological findings and EEG features was assessed. RESULTS In 81 patients with median neurotoxicity grade 3 (IQR 2-3), diffuse EEG background slowing was the most common finding and correlated with neurotoxicity severity (p <0.001). A total of 42 patients had rhythmic or periodic patterns, 16 of them within the ictal-interictal-continuum (IIC), 5 with clinical seizures, and 3 with only electrographic seizures. Focal EEG abnormalities, consisting of lateralized periodic discharges (LPD, n=1), lateralized rhythmic delta activity (LRDA, n=6), or focal slowing (n=19), were found in 22 patients. All patients with LRDA, LPD, and 10/19 patients with focal slowing had focal clinical symptoms concordant with these EEG abnormalities. In addition, these focal EEG changes often correlated with PET hypometabolism or MRI hypoperfusion, in absence of a structural lesion. CONCLUSION In adult patients experiencing neurotoxicity after CAR T cell infusion, EEG degree of background disorganization correlated with neurotoxicity severity. IIC patterns and focal EEG abnormalities are frequent and often correlate with focal clinical symptoms and with PET-hypometabolism/MRI-hypoperfusion, without structural lesion. The etiology of these findings remains to be elucidated.
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Affiliation(s)
- Isabelle Beuchat
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Husain Danish
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel B Rubin
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Caron Jacobson
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Matthew Robertson
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, MA, USA
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Yin Z, Zhang Y, Wang X. Advances in chimeric antigen receptor T-cell therapy for B-cell non-Hodgkin lymphoma. Biomark Res 2021; 9:58. [PMID: 34256851 PMCID: PMC8278776 DOI: 10.1186/s40364-021-00309-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/11/2021] [Indexed: 12/20/2022] Open
Abstract
B-cell non-Hodgkin lymphoma (B-NHL) is a group of heterogeneous disease which remains incurable despite developments of standard chemotherapy regimens and new therapeutic agents in decades. Some individuals could have promising response to standard therapy while others are unresponsive to standard chemotherapy or relapse after autologous hematopoietic stem-cell transplantation (ASCT), which indicates the necessity to develop novel therapies for refractory or relapsed B-NHLs. In recent years, a novel cell therapy, chimeric antigen receptor T-cell therapy (CAR-T), was invented to overcome the limitation of traditional treatments. Patients with aggressive B-NHL are considered for CAR-T cell therapy when they have progressive lymphoma after second-line chemotherapy, relapse after ASCT, or require a third-line therapy. Clinical trials of anti-CD19 CAR-T cell therapy have manifested encouraging efficacy in refractory or relapsed B-NHL. However, adverse effects of this cellular therapy including cytokine release syndrome, neurotoxicity, tumor lysis syndrome and on-target, off-tumor toxicities should attract our enough attention despite the great anti-tumor effects of CAR-T cell therapy. Although CAR-T cell therapy has shown remarkable results in patients with B-NHL, the outcomes of patients with B-NHL were inferior to patients with acute lymphoblastic leukemia. The inferior response rate may be associated with physical barrier of lymphoma, tumor microenvironment and low quality of CAR-T cells manufactured from B-NHL patients. Besides, some patients relapsed after anti-CD19 CAR-T cell therapy, which possibly were due to limited CAR-T cells persistence, CD19 antigen escape or antigen down-regulation. Quite a few new antigen-targeted CAR-T products and new-generation CAR-T, for example, CD20-targeted CAR-T, CD79b-targeted CAR-T, CD37-targeted CAR-T, multi-antigen-targeted CAR-T, armored CAR-T and four-generation CAR-T are developing rapidly to figure out these deficiencies.
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Affiliation(s)
- Zixun Yin
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China.,School of Medicine, Shandong University, Jinan, 250021, Shandong, China
| | - Ya Zhang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,School of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250012, Shandong, China. .,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021, Shandong, China. .,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, 250021, Shandong, China. .,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, 251006, China.
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,School of Medicine, Shandong University, Jinan, 250021, Shandong, China. .,Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250012, Shandong, China. .,Shandong Provincial Engineering Research Center of Lymphoma, Jinan, 250021, Shandong, China. .,Branch of National Clinical Research Center for Hematologic Diseases, Jinan, 250021, Shandong, China. .,National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou, 251006, China.
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Rubin DB, Al Jarrah A, Li K, LaRose S, Monk AD, Ali AB, Spendley LN, Nikiforow S, Jacobson C, Vaitkevicius H. Clinical Predictors of Neurotoxicity After Chimeric Antigen Receptor T-Cell Therapy. JAMA Neurol 2021; 77:1536-1542. [PMID: 32777012 DOI: 10.1001/jamaneurol.2020.2703] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Chimeric antigen receptor (CAR) T-cell therapy for relapsed or refractory hematologic malignant neoplasm causes severe neurologic adverse events ranging from encephalopathy and aphasia to cerebral edema and death. The cause of neurotoxicity is incompletely understood, and its unpredictability is a reason for prolonged hospitalization after CAR T-cell infusion. Objective To identify clinical and laboratory parameters predictive of neurotoxicity and to develop a prognostic score associated with its risk. Design, Setting, and Participants This single-center diagnostic/prognostic accuracy study was conducted at Brigham and Women's Hospital/Dana Farber Cancer Institute from April 2015 to February 2020. A consecutive sample of all patients undergoing CAR T-cell therapy with axicabtagene ciloleucel for relapsed or refractory lymphoma were assessed for inclusion (n = 213). Patients who had previously received CAR T cells or who were treated for mantle cell lymphoma were excluded (n = 9). Patients were followed up for a minimum of 30 days from the date of CAR T-cell infusion. Main Outcomes and Measures The primary outcomes were measures of performance (accuracy, sensitivity, specificity, area under the curve) of a diagnostic tool to predict the occurrence of CAR-associated neurotoxicity, as graded by the Common Terminology Criteria for Adverse Events criteria. Results Two hundred four patients (127 men [62.2%]; mean [SD] age, 60.0 [12.1] years) were included in the analysis, of which 126 (61.8%) comprised a derivation cohort and 78 (38.2%), an internal validation cohort. Seventy-three patients (57.9%) in the derivation cohort and 45 patients (57.7%) in the validation cohort experienced neurotoxicity. Clinical and laboratory values obtained early in admission were used to develop a multivariable score that can predict the subsequent development of neurotoxicity; when tested on an internal validation cohort, this score had an area under the curve of 74%, an accuracy of 77%, a sensitivity of 82%, and a specificity of 70% (positive:negative likelihood ratio, 2.71:0.26). Conclusions and Relevance The score developed in this study may help predict which patients are likely to experience CAR T-cell-associated neurotoxicity. The score can be used for triaging and resource allocation and may allow a large proportion of patients to be discharged from the hospital early.
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Affiliation(s)
- Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ali Al Jarrah
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Karen Li
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah LaRose
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew D Monk
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ali Basil Ali
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lauren N Spendley
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Sarah Nikiforow
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Caron Jacobson
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Shalabi H, Gust J, Taraseviciute A, Wolters PL, Leahy AB, Sandi C, Laetsch TW, Wiener L, Gardner RA, Nussenblatt V, Hill JA, Curran KJ, Olson TS, Annesley C, Wang HW, Khan J, Pasquini MC, Duncan CN, Grupp SA, Pulsipher MA, Shah NN. Beyond the storm - subacute toxicities and late effects in children receiving CAR T cells. Nat Rev Clin Oncol 2021; 18:363-378. [PMID: 33495553 PMCID: PMC8335746 DOI: 10.1038/s41571-020-00456-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 12/15/2022]
Abstract
As clinical advances with chimeric antigen receptor (CAR) T cells are increasingly described and the potential for extending their therapeutic benefit grows, optimizing the implementation of this therapeutic modality is imperative. The recognition and management of cytokine release syndrome (CRS) marked a milestone in this field; however, beyond the understanding gained in treating CRS, a host of additional toxicities and/or potential late effects of CAR T cell therapy warrant further investigation. A multicentre initiative involving experts in paediatric cell therapy, supportive care and/or study of late effects from cancer and haematopoietic stem cell transplantation was convened to facilitate the comprehensive study of extended CAR T cell-mediated toxicities and establish a framework for new systematic investigations of CAR T cell-related adverse events. Together, this group identified six key focus areas: extended monitoring of neurotoxicity and neurocognitive function, psychosocial considerations, infection and immune reconstitution, other end organ toxicities, evaluation of subsequent neoplasms, and strategies to optimize remission durability. Herein, we present the current understanding, gaps in knowledge and future directions of research addressing these CAR T cell-related outcomes. This systematic framework to study extended toxicities and optimization strategies will facilitate the translation of acquired experience and knowledge for optimal application of CAR T cell therapies.
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Affiliation(s)
- Haneen Shalabi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Juliane Gust
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Agne Taraseviciute
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Pamela L Wolters
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Allison B Leahy
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Carlos Sandi
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
- St. Baldrick's Foundation, Monrovia, CA, USA
| | - Theodore W Laetsch
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pediatrics and Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX, USA
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA
| | - Rebecca A Gardner
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Veronique Nussenblatt
- National Institute of Allergy and Infectious Disease, Clinical Center, NIH, Bethesda, MD, USA
| | - Joshua A Hill
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin J Curran
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Timothy S Olson
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Annesley
- Seattle Children's Research Institute, Seattle, WA, USA
- Department of Pediatrics, University of Washington Seattle, Seattle, WA, USA
| | - Hao-Wei Wang
- Laboratory of Pathology, NCI, NIH, Bethesda, MD, USA
| | - Javed Khan
- Oncogenomics Section, Genetics Branch, NCI, NIH, Bethesda, MD, USA
| | - Marcelo C Pasquini
- Blood and Marrow Transplant and Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI, USA
| | - Christine N Duncan
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Stephan A Grupp
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Pulsipher
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, NCI, NIH, Bethesda, MD, USA.
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Diagnostic biomarkers to differentiate sepsis from cytokine release syndrome in critically ill children. Blood Adv 2021; 4:5174-5183. [PMID: 33095872 DOI: 10.1182/bloodadvances.2020002592] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/30/2020] [Indexed: 01/10/2023] Open
Abstract
Chimeric antigen receptor (CAR) T-cells directed against CD19 have drastically altered outcomes for children with relapsed and refractory acute lymphoblastic leukemia (r/r ALL). Pediatric patients with r/r ALL treated with CAR-T are at increased risk of both cytokine release syndrome (CRS) and sepsis. We sought to investigate the biologic differences between CRS and sepsis and to develop predictive models which could accurately differentiate CRS from sepsis at the time of critical illness. We identified 23 different cytokines that were significantly different between patients with sepsis and CRS. Using elastic net prediction modeling and tree classification, we identified cytokines that were able to classify subjects as having CRS or sepsis accurately. A markedly elevated interferon γ (IFNγ) or a mildly elevated IFNγ in combination with a low IL1β were associated with CRS. A normal to mildly elevated IFNγ in combination with an elevated IL1β was associated with sepsis. This combination of IFNγ and IL1β was able to categorize subjects as having CRS or sepsis with 97% accuracy. As CAR-T therapies become more common, these data provide important novel information to better manage potential associated toxicities.
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Abdel-Mannan O, Eyre M, Löbel U, Bamford A, Eltze C, Hameed B, Hemingway C, Hacohen Y. Neurologic and Radiographic Findings Associated With COVID-19 Infection in Children. JAMA Neurol 2021; 77:1440-1445. [PMID: 32609336 DOI: 10.1001/jamaneurol.2020.2687] [Citation(s) in RCA: 263] [Impact Index Per Article: 87.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Neurological manifestations have been reported in adults with coronavirus disease 2019 (COVID-19), which is caused by the highly pathogenic virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Objective To report the neurological manifestations of children with COVID-19. Design, Setting, and Participants In this case-series study, patients younger than 18 years who presented with SARS-CoV-2 infection and neurological symptoms to Great Ormond Street Hospital for Children (London, UK) between March 1, 2020, and May 8, 2020, were included after infection was confirmed by either a quantitative reverse transcription-polymerase chain reaction assay by nasopharyngeal swab or a positive test result for IgG antibodies against SARS-CoV-2 in serum. Main Outcomes and Measures Clinical and paraclinical features were retrieved from electronic patient records. Results Of the 27 children with COVID-19 pediatric multisystem inflammatory syndrome, 4 patients (14.8%) who were previously healthy had new-onset neurological symptoms. Symptoms included encephalopathy, headaches, brainstem and cerebellar signs, muscle weakness, and reduced reflexes. All 4 patients required intensive care unit admission for the treatment of COVID-19 pediatric multisystem inflammatory syndrome. Splenium signal changes were seen in all 4 patients on magnetic resonance imaging of the brain. In the 2 patients whose cerebrospinal fluid was tested, samples were acellular, with no evidence of infection on polymerase chain reaction or culture (including negative SARS-CoV-2 polymerase chain reaction results) and negative oligoclonal band test results. In all 3 patients who underwent electroencephalography, a mild excess of slow activity was found. Tests for N-methyl-d-aspartate receptor, myelin oligodendrocyte glycoprotein, and aquaporin-4 autoantibodies had negative results in all patients. In all 3 patients who underwent nerve conduction studies and electromyography, mild myopathic and neuropathic changes were seen. Neurological improvement was seen in all patients, with 2 making a complete recovery by the end of the study. Conclusions and Relevance In this case-series study, children with COVID-19 presented with new neurological symptoms involving both the central and peripheral nervous systems and splenial changes on imaging, in the absence of respiratory symptoms. Additional research is needed to assess the association of neurological symptoms with immune-mediated changes among children with COVID-19.
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Affiliation(s)
- Omar Abdel-Mannan
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Michael Eyre
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Ulrike Löbel
- Department of Neuroradiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Alasdair Bamford
- UCL Great Ormond Street Institute of Child Health, Department of Infectious Disease, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Christin Eltze
- UCL Great Ormond Street Institute of Child Health, Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Biju Hameed
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Cheryl Hemingway
- UCL Great Ormond Street Institute of Child Health, Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Yael Hacohen
- Department of Neurology, Great Ormond Street Hospital for Children, London, United Kingdom.,Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology, Faculty of Brain Sciences, University College London, London, United Kingdom
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Tedesco VE, Mohan C. Biomarkers for Predicting Cytokine Release Syndrome following CD19-Targeted CAR T Cell Therapy. THE JOURNAL OF IMMUNOLOGY 2021; 206:1561-1568. [PMID: 33692146 DOI: 10.4049/jimmunol.2001249] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
Chimeric Ag receptor (CAR) T cell therapy has shown astonishing potency in treating a variety of hematological malignancies in recent years. Along with this lifesaving potential comes the life-threatening toxicities of cytokine release syndrome (CRS) and neurotoxicity. This work seeks to consolidate biomarker candidates with the potential to predict the severity of CRS and neurotoxicity in patients receiving CD19-targeted CAR T cell therapy. In this systematic review, 33 clinical trials were evaluated for biomarkers that can predict the severity of posttreatment CRS and neurotoxicity. CRS and neurotoxicity occurred in 73.4 and 37% of the reviewed patients, respectively. Identified biomarker candidates included tumor burden, platelet count, C-reactive protein, ferritin, IFN-γ, IL-2, IL-6, IL-8, IL-10, IL-15, and TGF-β. Combinatorial algorithms based on cytokine levels and clinical parameters show excellent promise in predicting CAR-T-cell-therapy-associated toxicities, with improved accuracy over the component biomarkers.
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Affiliation(s)
- Victor E Tedesco
- Department of Biomedical Engineering, University of Houston, Houston, TX 77004
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, TX 77004
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Hong R, Hu Y, Huang H. Biomarkers for Chimeric Antigen Receptor T Cell Therapy in Acute Lymphoblastic Leukemia: Prospects for Personalized Management and Prognostic Prediction. Front Immunol 2021; 12:627764. [PMID: 33717147 PMCID: PMC7947199 DOI: 10.3389/fimmu.2021.627764] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/18/2021] [Indexed: 12/15/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy represents a breakthrough in immunotherapy with the potential of ushering in a new era in cancer treatment. Remarkable therapeutic response and complete remission of this innovative management have been observed in patients with relapse/refractory acute lymphoblastic leukemia. With CAR-T cell therapy becoming widely used both in multicenter clinical trials and as a commercial treatment, therapeutic efficacy monitoring and management of toxicities will be indispensable for ensuring safety and improving overall survival. Biomarkers can act not only as effective indicators reflecting patients' baseline characteristics, CAR-T cell potency, and the immune microenvironment, but can also assess side effects during treatment. In this review, we will elaborate on a series of biomarkers associated with therapeutic response as well as treatment-related toxicities, and present their current condition and latent value with respect to the clinical utility. The combination of biomarker research and CAR-T cell therapy will contribute to establishing a safer and more powerful monitoring system and prolonging the event-free survival of patients.
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Affiliation(s)
- Ruimin Hong
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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